UVM Environmental Safety Facility

Risk Designation Form

Infectious Materials Risk Designation Form

This form must be completed for every at-risk employee, and the form should be kept in the department's personnel files. Designations for new employees must be made within 10 days of the employee's arrival at work, and at-risk employees must be offered the Hepatitis B vaccine within this time period. If they consent to receive the vaccine, they should be directed to make an appointment to receive the vaccine series at

Concentra Managed Care
7 Fayette Road
South Burlington, VT
658-5756

Employees need to bring a completed copy of this form to their first vaccination appointment. This will assure that the cost of the series is charged to the UVM Occupational Health budget. At risk employees must also take the on line bloodborne pathogens training.

Date:

Employee name:

Employee position title:

Department:

Supervisor Name:

The above named employee will be subject to possible exposure to bloodborne pathogens or other potentially infectious materials as defined below while performing their duties in my department.
Signature - Principal Investigator or Supervisor

Definitions:

Bloodborne pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans.

Other potentially infectious materials means human semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visibly contaminated with blood, and all body fluids in situa tions where it is difficult or impossible to differentiate between body fluids. In addition, any unfixed tissue or organ from a human (living or dead) and any pathogen contaminated cell or tissue cultures, organ cultures, pathogen contaminated culture medium or solutions, or tissues from pathogen contaminated animals.

Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on any item or surface, including laundry.

Maintain a copy of this form to in the employee's personnel record.

If you have any questions about this, call 656-5400

From the UVM Risk Management web site

File URL: http://esf.uvm.edu/uvmecp/appendixd.html

esf@uvm.edu

Version 5.0

Last Revised:

May 9, 2011