ATTACHMENT A

 BLOODBORNE PATHOGEN

RISK APPRAISAL SURVEY

(To be completed annually by each Administrative Unit within the University.  Completed surveys should be returned by October 1 to the Office of Environmental Health and Safety.)

RISK APPRAISAL SURVEY

Department ___________________________                                    Date _____________

Name and Phone Number of Supervisor Completing This Form: __________________________________

__________________________________

Student/Employee Exposure to Bloodborne Pathogens

Risk Appraisal Survey

    The purpose of this survey is to identify job classifications and courses in which employees or students within your Administrative Unit are at risk for occupational or student academic exposure to bloodborne pathogens.  In addition, this survey will be used to identify specific employees or students within your Administrative Unit who are at risk for occupational or student academic exposure to bloodborne pathogens.

Occupational Exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of any employee's duties whether on or off campus.

Student Academic Exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the student's participation in academic assignments or activities.

Other Potentially Infectious Materials means:

A.     The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids.

B.     Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and

C.     HIV - containing cell or tissue cultures, organ cultures, and HIV or HBV - containing culture medium or other solutions: and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

Employees at Risk for Occupational Exposure

Please list the job classifications in your Administrative Unit where all employees will have reasonably anticipated exposure to human blood or other potentially infectious materials:

(Attach additional pages if necessary)

Please list the job classifications and work activities in your Administrative Unit in which some of the employees will have reasonably anticipated exposure to human blood and other potentially infectious materials:

(Attach additional pages if necessary)

Please list the names of all employees in your Administrative Unit who are at risk for occupational exposure to bloodborne pathogens.

(Attach additional pages if necessary)

Students at Risk for Student Academic Exposure

Please list the name, number, and responsible faculty member for each course or describe each university-sponsored activity in your Administrative Unit where there may be student academic exposure to bloodborne pathogens.

(Attach additional pages if necessary)

Please return this form by October 30 to the University Office of Environmental Health and Safety, Box 870178, 15 Research Drive.  Please call Hal Barrett at the Office of Environmental Health and Safety if you need assistance with completing this form (348-5905).