Building a Model

of Hospital WMD Preparedness upon the Veterans Health Administration's

Extensive Expertise in Managing Hazardous Materials and Wastes

### 

### 

### Review of the Literature 

### And Initial Recommendations

### 

### 6/2000

### 

### 

### Education and Research

### Emergency Management SHG 

### Preface

The Emergency Management Strategic Healthcare Group (EMSHG), Education
and Research section was assigned the task of developing a "pilot
project" for preparing the VHA health care system for terrorist use of
Weapons of Mass Destruction. The goal of the project was described as:

*"...{To} explore how best to prepare, train and exercise our VA health
care facilities to [protect]{.underline} VA patients, staff and
facilities from contamination in the event of a WMD {weapons of mass
destruction} incident."*[^1]

The purpose of this paper is to summarize information gained through a
search of regulations and literature concerning the decontamination of
patients who arrive at a hospital for treatment. It encompasses
contamination primarily from chemical agents, since they represent the
greatest potential threat to staff, visitors and patients (as opposed to
biological and radioactive agents (see Appendix A for rationale)). This
discussion is limited to providing information only for patient
decontamination, and not the multitude of other considerations a
hospital must address in preparing for disasters and/or terrorism. The
following is presented in an interrogatory fashion in order to identify
and attempt to resolve some of the major issues.

Table of Contents

Introduction 5

Must VA comply with SARA Title III? 7

What are the responsibilities of VA health care facilities? 7

At VA Medical Centers, how are these responsibilities organized? 8

What training requirements exist for HAZCOM? 8

Does OSHA review training materials or courses? 9

If an employee spills or releases hazardous chemicals, is this an
emergency response as defined by OSHA 1910.120 or at what point does an
emergency occur? 9

Does HAZWOPER apply to hospitals? 9

If a contaminated patient presents in the emergency department, is this
an "emergency response?" 10

What are the specific JCAHO requirements? 10

That statement does not require each facility to maintain its own
facilities, it just requires each facility identify a facility for
isolation and decontamination, isn't that correct? 10

Can the VHA health care facility just refuse a contaminated patient,
especially if they are not eligible for care? 11

Can an employee who is not trained nor equipped to handle such a
situation refuse to participate? 11

If the workers in this situation refused due to a lack of training and
equipment, who would provide care to the victims? 11

Does the existence of a "disaster" waive OSHA regulations? 12

Where should decontamination occur? 12

What needs to be done to adequately prepare for this situation? 12

JCAHO mandates the hospital be part of the community-wide planing
effort, what support is available from the community? 13

If medical personnel will only be performing medical care while others
are perform decontamination, do they need to be trained in accordance
with 1910.120? 14

What are the levels of training for emergency responders? 14

What are the continuing education requirements? 15

If hospitals will have to comply with the HAZWOPER standard, must an
incident commander be on-site at all times (24/7) or on call? 15

Who certifies the competency of employees, the employer or OSHA? 16

How is the correct level of PPE selected? 16

Who is required to pay for PPE, the employer or employee? 17

Are there particular training requirements for those who wear PPE? 18

Do all designated emergency response personnel involved in a
decontamination operation at a hospital require medical surveillance? 19

How does SARA Title III apply to preparedness to WMD? 19

Bibliography 20

Appendix A -- Excerpts from the IOM Report 22

Appendix B -- Training Curriculum Guidelines (29 CFR 1910.120) 28

Appendix C -- Training, Personal Protective Equip. (29 CFR 1910.132) 34

Appendix D -- Requirements of Training Programs (29 CFR 1910.1200) 36

Building a Model of Hospital WMD Preparedness upon the Veterans Health
Administration's Extensive Expertise in Managing Hazardous Materials and
Wastes

# Introduction

This report is intended to introduce the reader to the subject of
hazardous substances and the adjustments American society have made to
control the risks associated with them. Its specific purpose is to
provide information necessary to develop a practical yet effective
capability within the Veterans Health Administration (VHA) to counter
the potential threat of harm to staff, visitors and patients from
contaminated persons presenting at a VHA health care facility. This
discussion is not limited to only victims of terrorism, but applies to
any situation and any spill of a contaminant harmful to human health and
the environment.

A sentinel event occurred in 1985 in Bhopal, India, in which thousands
were killed and injured as a result of the release of a toxic gas from a
nearby industrial facility. Congress responded to the concerns from such
a disaster occurring in the United States by enacting the Superfund
Amendments and Reauthorization Act (SARA) of 1986, amending the
Comprehensive Environmental Response, Compensation and Liability Act
(CERCLA) of 1980. The basic purpose of Title III of SARA, also known as
the Emergency Planning and Community Right-to-Know Act (EPCRA) was "to
promote emergency planning to respond to chemical releases and to ensure
that information regarding chemicals in the community is available to
the public and to emergency response agencies. These are accomplished
by:

a\. Establishing State Emergency Response Commissions (SERCs) and Local
Emergency Planning Committees (LEPCs) with responsibility to develop
emergency plans to be followed in the event of an emergency chemical
release.

b\. Implementing a series of notification and reporting requirements to
state and local emergency planning activities with respect to type and
quantities of specific chemicals.

c\. Promoting the development of local response plans and procedures in
the event of an emergency chemical release." [^2]

Occupational Safety and Health Administration (OSHA) regulations for
hazardous substances are found in 29 CFR Part 1910. Of specific interest
to this discussion are Subparts H, I and Z:

Subpart H -- Hazardous Materials (1910.101-.126)

> 1910.120 - Hazardous Waste Operations and Emergency Response
> (HAZWOPER) and Appendices A-E.

Subpart I -- Personal Protective Equipment (1910.132-.139 and App. B)

1910.132 -- General Provisions

1910.133 -- Eye and Face Protection

1910.134 -- Respiratory Protection (and App. A-D)

1910.136 -- Occupational Foot Protection

1910.138 -- Hand Protection

> Subpart Z -- Toxic & Hazardous Substances (1910.1000-.1450 App B)

1910.1200 -- Hazard Communication (and App. A-E)

1960.70 -- Reporting to OSHA

1960, Part H

1910.1201 -- Retention of DoT markings, placards and labels

1910.1020 -- Access to employee exposure and medical records

In order to facilitate a basic understanding of how these laws and
regulations come into play in the workplace and their relationship to
each other, it is important to start with the policy that an employee
has the right to a safe and healthful workplace. [^3] In workplaces that
manufacture, use, store and/or dispose of hazardous substances[^4], the
OSHA regulation 1910.1200, Hazard Communication, says that
[all]{.underline} employees must be informed about hazardous substances
in the workplace and understand protective measures. Other OSHA
regulations come into effect for employees who are exposed to hazardous
substances. The Environmental Protection Agency (EPA) compels employers
whose employees handle hazardous materials and wastes to follow certain
guidelines set forth in the EPCRA, including engaging in planning for
emergency spills or releases. Finally, OSHA regulation 1910.120
(HAZWOPER) establishes health and safety standards for those involved in
responding to emergencies involving hazardous materials.

Thus, there are four key factors: an employees right to a safe and
healthful workplace; an employers duty to inform employees about
hazardous substances in the workplace; an employers responsibility to
coordinate with community emergency planning groups; and, an employers
duty to provide adequate protection for employees who may come in
contact with hazardous materials. These will be explained in the
following section.

1\. Must VA comply with the Superfund Amendments and Reauthorization Act
(SARA Title III)?

Yes. The Department of Veterans Affairs (VA) is required by the
Environmental Protection Agency (EPA) to participate in an Emergency
Planning and Community Right-to-Know Program (EPCRA). [^5]

##### 2. What are the responsibilities of VHA health care facilities?

It is the policy of the Veterans Health Administration (VHA) that "each
facility shall establish and participate in an EPCRA in accordance with
the guidelines of this Directive and consistent with all Federal, state
and local regulations.

Health Care Facility Directors shall:

a\. Establish and participate in an effective EPCRA.

b\. Appoint an Emergency Response Coordinator (ERC) or other qualified
individual to administer the facility EPCRA and serve as a point of
contact with the LEPC. If necessary, the ERC shall represent the
facility on the LEPC. The Emergency Medical Preparedness Area Manager
can serve in this capacity, if available.

c\. Coordinate with the LEPC and other Federal, state and local agencies
to include, as a minimum, the following:

1). Participating in SARA Title III planning activities.

2). Discussing with the LEPC the potential for spills or releases of
chemicals on the Extremely Hazardous List and their Threshold Planning
Quantities as published in the most recent Title 40 CFR Part 355,
Appendices A and B, and:

3). Reviewing proposed hazardous chemicals and quantities which would
require additional reporting to LEPCs.

d\. Reporting spills or releases of chemicals on the Extremely Hazardous
List or other chemicals as required.

e\. Provide upon request the nature and quantity or chemicals on the
Extremely Hazardous List or other chemicals as may be required.

f\. Review annually and updating facility inventories of hazardous
chemicals and wastes.

NOTE: VHA Directive 98-011, Management of Hazardous Chemicals, provides
specific procedures for ensuring that hazardous chemicals are used,
handled, stored and disposed of in a manner consistent with regulatory,
statutory and accrediting requirements and accepted safe practices."

##### 3. At an average VA Medical Center, how are these responsibilities organized? 

Compliance with the requirements of the EPCRA involves two related
programs:

The [Hazard Communication Program]{.underline} ensures employees are
informed and trained on the safe handling of hazardous chemicals in the
workplace, including the proper storage, handling, labeling, spill, leak
and disposal procedures. This includes a hazardous chemical inventory,
material safety data sheets, labels and other forms of warning, training
and communication with appropriate supervisors prior to the conduct of
non-routine tasks that might expose employees to hazardous chemicals.

At some but not all VA Medical Centers, the Hazard Communication Program
involves the Industrial Hygienist (often charged as the Hazard
Communication Program coordinator); Service Chiefs in whose departments
hazardous chemicals are used, stored or disposed of; Acquisition and
Materiel Management (whose role includes ensuring incoming substances
are labeled, and informing contractors at work within the facility about
hazardous chemicals in the vicinity of that work), and Engineering,
whose role includes obtaining contractor material safety data sheets and
providing them to the Industrial Hygienist.[^6]

The [Hazardous Waste Management Program]{.underline} is also required by
a variety of Federal, State and local agency laws and regulations and
the JCAHO. Once generated, hazardous wastes must be labeled, handled,
stored and disposed of in a manner consistent with their
characteristics, which can be difficult to ascertain. A major goal of
this program is the reduction and recycling of hazardous substances. The
organization for this program mirrors that of the program for the Hazard
Communication Standard. [^7]

##### 4. What training requirements exist for HAZCOM?

The Hazard Communication Standard (1910.1200) is a performance-based
standard. This means that employers have the flexibility to adapt the
rule to the needs of their workplace, rather than having to follow
specific, rigid requirements. The HCS, at section (h), sets forth the
elements that must be included in an employer\'s hazard communication
training. According to the standard, employee training must consist of
the following elements:

-   Discussion on how to read and to interpret information on the
    Material Safety Data Sheets (MSDS) and on the container labels

-   How employees can obtain and use the hazard information that is
    available and how the hazard communication program is implemented in
    their workplace.

-   The hazards of the chemicals in the work area and the measures that
    the employees can take to protect themselves from the hazards.

-   The specific procedures that the employer uses to provide protection
    such as engineering controls, work practices, and the use of
    personal protective equipment.

-   Include the methods and observations that the workers can use to
    detect the presence a hazardous chemical to which they may be
    exposed.

##### 5. Does OSHA review training materials or courses?

No. OSHA does not perform reviews of employer training materials to
determine if their use will render the user in compliance with our
standards. Further, OSHA does not approve nor does it endorse
commercially available training programs.

It is up to the employer to decide whether any particular training
program meets the intent of the Standard. As you can see, many of the
areas that must be addressed in hazard communication training are
workplace specific - for example, training on the specific chemical
hazards at your workplace [^8]

6\. If an employee spills or releases hazardous chemicals, this is an
emergency response as defined under OSHA 1910.120, or at what point does
an "emergency" occur?

Incidental releases that can be safely handled by the workers who
spilled the substance are not considered emergency responses and
therefore are not covered under 1910.120. However, other training
requirements, such as those found in the Hazard Communication Standard
(1910.1200) would apply.[^9]

An emergency response is defined as a "coordinated response effort by
employees from outside the immediate release area or by outside
responders (i.e., mutual-aid groups, fire departments, etc.) to an
occurrence which results, or is likely to result, in an uncontrolled
release of a hazardous substance."[^10]

##### 7. Does HAZWOPER apply to hospitals?

"After considerable review OSHA interprets the scope of 1910.120
{HAZWOPER) to cover hospitals in at least three scenarios: 1). When
hospitals have an internal release of a hazardous substance which
requires an emergency response; 2). When hospitals respond as an
integral unit in a community-wide emergency response to a release of
hazardous substance; and, 3). If a hospital is a RCRA {Resource
Conservation and Recovery Act)-permitted Treatment, Storage and Disposal
Facility." [^11]

The HAZWOPER standard does not define an emergency in terms of the
quantity of the substance spilled. The term \"emergency\" is dependent
upon several factors, including the hazards associated with the
substance, the exposure level, the potential for danger and the ability
to contain the substance. This analysis is the responsibility of
employers since they are most familiar with the specific hazards of the
substance as it is used in their work places and the potential for an
emergency. The burden of proving that there is no potential for an
emergency at a work site likewise properly belongs to the employer.[^12]

8\. If a contaminated patient presents in the emergency department, is
this an "emergency response?"

Yes. OSHA does not require hospitals to receive accident victims,
however, if the victim was part of an emergency involving hazardous
substances and hospital personnel needed to decontaminate, OSHA
regulations 29 CFR 1910.120 (HAZWOPER) would apply.[^13]

##### 9. What are the specific JCAHO requirements?

The organization designs (EC 1) and provides (EC 2) a safe, accessible,
effective and efficient environment of care consistent with its mission,
services and law and regulation. This includes the design of management
plans for the control of hazardous materials and emergency preparedness
(EC 1.5 and 1.6, respectively), as well as staff orientation and
education on the environment of care and "possess the knowledge and
skills to perform their responsibilities under the environment of care
management plans" (EC 2.4 and 2.5, respectively). One specific standard
relates to, "the {emergency preparedness management} plan identifies
facilities for radioactive or chemical isolation and decontamination"
(EC 1.6(l)).

10\. That statement does not require each facility to maintain its own
facilities, it just requires that each facility identify a facility for
isolation and decontamination, isn't that correct?

Yes, but the requirement that each healthcare facility maintain such
facilities is required by SARA Title III (for the isolation and
decontamination of employees from spills and releases occurring through
the use of hazardous substances in the workplace). Further, hospitals
are required to participate in the community-wide emergency response
planning for hazardous materials by both JCAHO and SARA Title III.

***11. Can the VHA health care facility just refuse a contaminated
patient, especially if they are not eligible for care?***

No, "the Consolidated Omnibus Budget Reconciliation Act (COBRA) mandates
the delivery of medical services individuals seeking care in an
emergency department. ... Every individual presenting to an emergency
department must receive a medical screening examination. Choosing not to
provide care to a contaminated individual, due to a lack of hazmat
training, is a potential COBRA law violation. Transferring the
potentially unstable (e.g., contaminated) patient without
decontamination may be in direct violation of COBRA. In addition, the
failure to treat may pose broader ethical questions." [^14]

It is also VA policy to provide humanitarian assistance, "which
represent a true medical emergency, medical care will be rendered until
such time that the patient's condition is stable enough that he/she can
either be transferred to another healthcare facility or sent home."[^15]

Since care cannot be refused, employees may be placed in harm's way by
the facility not preparing an adequate solution to this potential
situation.

12\. Can an employee who is not trained nor equipped to handle such a
situation refuse to participate?

Yes, an employer could not force an employee to perform work in a
situation such as this. The OSHA Hazard Communication Standard states
that every worker has the right to a hazard-free work environment. VA
Directive 7700 states it is VA policy to "maintain safe and healthful
work environments for employees through the elimination of safety and
health hazards and through the development of safe work practices {and}
afford VA employees working at a non-VA facility protection equal to
that required by the VA Occupational Safety and Health (OSH) program.
This Directive "references safety and health standards, executive
orders, VA directives and handbooks and the Code of Federal Regulations
as the primary sources for government-wide guidelines."

***13. If the workers in this situation refused due to a lack of
training and equipment, who would provide care to the victim(s)?***

Staff should dial 9-1-1 and describe the situation to the dispatcher.
Fire-rescue, hazardous materials and emergency medical service personnel
would perform initial triage and gross decontaminate, provide supportive
treatment and transport the patient to an appropriate facility.
Repercussions from such a scenario would include the need to temporarily
close the area in order to decontaminate it, provide medical screening
to those who came in close contact with the person(s) and carefully
address inquiries from the media realizing that negative publicity and
legal actions will probably ensue.

##### 14. Does the existence of an "disaster" waive OSHA regulations?

No. The existence of a disaster does not exempt Federal agencies from
all applicable OSHA standards. "In accordance with applicable OSHA and
other agency regulations, all signatory agencies to the Federal Response
Plan are responsible for protecting the safety and health of their
personnel deployed to a disaster or disaster exercise." [^16]

***15. Where should decontamination occur?***

"The ideal situation is for decontamination to take place in the field
and for this to be performed by specially trained HAZMAT teams. In this
case, the subsequent pre-hospital and hospital care can be performed
with little change in the usual routine and with minimal risk to health
care providers. In situations where there are several hospitals in a
given area, it is not financially feasible for all hospitals to have
good decontamination facilities. One hospital should be chosen as the
receiving facility. The choice of hospital should be based on the
availability of decontamination facilities, intensive care facilities,
training of ED personnel and staff trained in medical toxicology.
Regardless of whether a hospital is a receiving facility or if it is in
an area where there is a trained HAZMAT team, there will always be
situations when contaminated patients present to the pre-hospital or
hospital systems. Thus, all hospitals should have a plan and appropriate
employee training for dealing with the contaminated patient." [^17]

##### 14. What needs to be done to adequately prepare for this situation?

"HAZWOPER requires that workers who will be part of an emergency
response unit be trained to perform their anticipated job duties without
endangering themselves or others. To determine the level and type of
training your workers need, you must consider the hazards in your
community and what capabilities your personnel need to respond to those
hazards. You should make your determination based on worst-case
scenarios.

If your personnel are expected to provide limited decontamination
services in order to attend to medical problems, they must be trained to
the first responder operations level with emphasis on the use of PPE and
decontamination procedures. {for an exception see inset, below}. This
level of emergency response training is described in 29 CFR
1910.120(q)(6)(ii); additional guidance about the content of this
training is available in HAZWOPER's Appendix E.

> Although hospitals that may be involved in emergency response are
> required to designate emergency responders and train them accordingly,
> other hospital personnel that may have to enter the decontamination
> area may not have to be trained as emergency responders. There is an
> exception to paragraph (q) training requirements for \"skilled support
> personnel.\" These employees are not required to have had emergency
> responder training, however, they must be given an initial briefing at
> the time of the incident, including instruction in the wearing of
> appropriate personal protective equipment, what chemical hazards are
> involved and what duties are to be performed. This category might
> include emergency room personnel as well as doctors and
> technicians."[^18]

Hospitals may develop in-house training or they may send personnel to a
standard first responder operations level course, then provide
additional training in decontamination and PPE as needed. HAZWOPER
requires the employer to certify that workers have the training and
competencies listed in (q)(6)(ii). The standard also requires annual
refresher training or demonstration of competency, as described in
(q)(8).

A hospital that expects its employees to handle emergencies involving
hazardous substances also needs to prepare a written emergency response
plan. Employees and affiliated personnel expected to be involved in an
emergency response including physicians, nurses, maintenance workers,
and

other ancillary staff should be (1) familiar with how the hospital
intends to respond to hazardous substance incidents, (2) trained in the
appropriate use of PPE, and (3) required to participate in scheduled
drills.

OSHA Publication 3152, Hospitals and Community Emergency Response - What
You Need to Know (1997), is an excellent reference on this topic. It
discusses the range of emergency response planning and training a
hospital needs to undertake, depending on its role in community
emergency response." [^19]

##### 15. JCAHO mandates the hospital be part of the community-wide planning effort, what support is available from the community?

"Under SARA Title III, communities must prepare an emergency response
plan. It is mandated by the statute that the local hospital participate
in the planning process."[^20]

Hospitals are responsible for providing training and equipment to their
own employees. For this reason, hospitals that may receive victims
contaminated with hazardous substances should coordinate with the Local
Emergency Planning Committee (LEPC) or the State Emergency Response
Commission (SERC). The LEPC or SERC is responsible for planning for
emergencies and providing funds to community emergency responders to
"improve emergency planning, preparedness, mitigation, response and
recovery capabilities." [^21]

16\. If medical personnel will only be performing medical care (while
others perform decontamination duties), do they need to be trained in
accordance with 1910.120?

Instruction for emergency medical personnel in topics under 29 CFR
1910.120(q)(6)(ii) that are not directly relevant to emergency medical
care is not necessary, although employees must be trained to perform the
duties and functions expected of them. This is considered a de minimis
violation, which

is reserved for employers who are not technically in compliance with a
regulation but who provide a safe and healthful working environment for
their employees." [^22]

***17. What are the levels of training for emergency responders?***

> Level 1: First Responder Awareness:
>
> This is the person who witnesses or discovers the release of hazardous
> material and notifies the proper authorities. Training includes
> recognition and identification of hazardous materials, notification
> procedures, and employee's role in the emergency release plan.
> Sufficient training or proven experience in specific competencies.
>
> Level 2: First Responder Operations:

Persons who respond to release of hazardous substances without trying to
stop the release. Requires Level 1 competency and 8 hours of additional
training in basic hazard and risk assessment, personal protective
equipment (PPE) selection, containment and control procedures,
decontamination and the emergency release plan (ERP).

> Level 3: Hazardous Materials Technician:
>
> This level responds aggressively to stop a release. It requires 24
> hours of Level 2 training and competencies in detailed risk
> assessment, toxicology, PPE selection, advanced control, containment
> and decontamination procedures, air-monitoring equipment and the
> incident command system (ICS).
>
> Level 4: Hazardous Materials Specialist:
>
> The specialist has advanced knowledge of hazardous materials and
> responds with and provides support to hazardous materials technicians.
> It requires 24 hours of Level 3 training and proven competencies,
> along with advanced instruction, on all specific hazardous material
> topics.
>
> Level 5: On-Site Incident Commander:
>
> This individual assumes control of the incident. Level 5 requires 24
> hours of training equivalent to Level 2 with competencies in the ICS
> and ERP, hazard and risk assessment and decontamination procedures.
> [^23]

##### 18. What are the continuing education requirements?

"All emergency response personnel covered by paragraph (q) must receive
refresher training, at least annually, to ensure that their skills and
competencies do not deteriorate and are not forgotten. Training that
expands the knowledge of emergency responders upward along the continuum
is acceptable to meet the annual refresher training requirements for the
year during which the training was received." [^24]

19\. If hospitals will have to comply with the HAZWOPER standard, must
an incident commander be on site at all times (for hospitals, 24 hours a
day, 7 days a week) or on call?

"Hospitals may come under OSHA\'s HAZWOPER standard (or EPA\'s
equivalent standard, 40 CFR 311, if it is a public hospital), depending
upon the level of activity they have chosen to undertake during in-house
emergencies. If the hospital has decided that a hospital staff member
will be the incident commander during an emergency, this person must
meet the training requirements found in 29 CFR 1910.120(q)(6) and be
able to implement the procedures for handling an emergency response as
outlined in 29 CFR 1910.120(q)(3).

The senior official responding to the emergency can be designated as the
individual in charge of the Incident Command System. As is explained in
the standard\'s \"note to (q)(3)(i),\" this can change as more senior
officers arrive on the scene. Therefore, you would not be required to
have an incident commander on site at all times, but a designated person
must be on call 24 hours a day. The

emergency response plan must identify the most senior official who will
be in charge until the designated incident commander arrives; this
person must be properly trained for the function to be performed. "
[^25]

##### 20. Who certifies the competency of employees, the employer or OSHA?

OSHA does not certify individuals, it is the employer who must show by
documentation or certification that an employee\'s work experience
and/or training meets the requirements of 1910.120. There must be a
written document which clearly identifies the employee, the person
certifying the employee, and the training and/or past experience which
meets the requirements. One possibility would be to include this
information in the employee\'s personnel file. The preferred method is
to include this information on a separate certificate for each
employee." [^26]

***21. How is the correct level of Personal Protective Equipment (PPE)
selected?***

From an assessment of lihely hazards, assuming the worst-case scenario.
29 CFR 1910.132 states:

"(d)(1) The employer shall assess the workplace to determine if hazards
are present, or are likely to be present, which necessitate the use of
personal protective equipment (PPE). If such hazards are present, or
likely to be present, the employer shall:

(d)(1)(i) Select, and have each affected employee use, the types of PPE
that will protect the affected employee from the hazards identified in
the hazard assessment;

(d)(1)(ii) Communicate selection decisions to each affected employee;
and,

(d)(1)(iii) Select PPE that properly fits each affected employee. Note:
Non-mandatory Appendix B contains an example of procedures that would
comply with the requirement for a hazard assessment.

(d)(2) The employer shall verify that the required workplace hazard
assessment has been performed through a written certification that
identifies the workplace evaluated; the person certifying that the
evaluation has been performed; the date(s) of the hazard assessment;
and, which identifies the document as a certification of hazard
assessment.

\(e\) Defective and damaged equipment. Defective or damaged personal
protective equipment shall not be used. ..1910.132(f)." [^27]

***22. Who is required to pay for PPE, the employer or employee?***

"OSHA policy requires employers to provide and to pay for personal
protective equipment (PPE) which is required for a worker to do his or
her job safely to comply with OSHA standards." [^28]

"The personal protective equipment standards at 29 CFR 1910.132 through
.138 establish the employer\'s obligation to provide personal protective
equipment to employees."

\"Protective equipment, including personal protective equipment for
eyes, face, head and extremities, protective clothing, respiratory
devices and protective shields and barriers, shall be provided, used and
maintained in a sanitary and reliable condition wherever it is necessary
by reasons of hazards of

processes or environment, chemical hazards, radiological hazards or
mechanical irritants encountered in a manner capable of causing injury
or impairment in the function of any part of the body through
absorption, inhalation or physical contact.\" (29 CFR 1910.132(a))

In order to accommodate work situations in which it is customary, as an
exception, for workers in a particular trade to provide their own PPE,
the standard acknowledges that employees may provide their own
equipment, but does not specify that practice as the norm; instead, the
standard underscores the employer\'s obligation to assure that such
equipment is adequate and that it is properly maintained.

The \"worker-provided\" clause on the PPE standard (1910.132(b)), now
also codified for the construction industry at 1926.95(b), has raised
questions as to when employers are required to pay for PPE. This
memorandum is intended to clarify the situation.

OSHA has interpreted its general PPE standard, as well as specific
standards, to require employers to provide and to pay for personal
protective equipment required by the company for the worker to do his or
her job safely and in compliance with OSHA standards. Where equipment is
very personal in nature and is usable by workers off the job, the matter
of payment may be left to

labor-management negotiations." [^29]

***23. Are there particular training requirements for those who wear
PPE?***

Yes, OSHA Standard 29 CFR 1910.132(f) states:

"(f)(1) The employer shall provide training to each employee who is
required by this section to use PPE. Each such employee shall be trained
to know at least the following:

(f)(1)(i) When PPE is necessary;

(f)(1)(ii) What PPE is necessary;

(f)(1)(iii) How to properly don, doff, adjust, and wear PPE;

(f)(1)(iv) The limitations of the PPE; and,

(f)(1)(v) The proper care, maintenance, useful life and disposal of the
PPE.

(f)(2) Each affected employee shall demonstrate an understanding of the
training specified in paragraph (f)(1) of this section, and the ability
to use PPE properly, before being allowed to perform work requiring the
use of PPE.

(f)(3) When the employer has reason to believe that any affected
employee who has already been trained does not have the understanding
and skill required by paragraph (f)(2) of this section, the employer
shall retrain each such employee. Circumstances where retraining is
required include, but are not limited to, situations where:

(f)(3)(i) Changes in the workplace render previous training obsolete; or
..1910.132(f)(3)(ii)

(f)(3)(ii) Changes in the types of PPE to be used render previous
training obsolete; or

(f)(3)(iii) Inadequacies in an affected employee\'s knowledge or use of
assigned PPE indicate that the employee has not retained the requisite
understanding or skill.

(f)(4) The employer shall verify that each affected employee has
received and understood the required training through a written
certification that contains the name of each employee trained, the
date(s) of training, and that identifies the subject of the
certification.

\(g\) Paragraphs (d) and (f) of this section apply only to 1910.133,
1910.135, 1910.136, and 1910.138. Paragraphs (d) and (f) of this section
do not apply to 1910.134 and 1910.137."[^30]

24\. Do all designated emergency response personnel involved in a
decontamination operation at a hospital require medical surveillance?

"No. Subparagraph (q)(9) requires that \"members of an organized and
designated HAZMAT team and hazardous materials specialists shall receive
a baseline physical examination and be provided with medical
surveillance as required in paragraph (f) of this section.\"
Additionally, any emergency

response employees who exhibit signs or symptoms which may have resulted
from exposure to hazardous substances during the course of an emergency
incident must be provided with medical consultation." [^31]

25\. How does SARA Title III apply to preparedness for Weapons of Mass
Destruction (WMD)?

WMD is defined as "any weapon or device that is intended, or has the
capability, to cause death or serious bodily injury to a significant
number of people through the release, dissemination or impact of: (A)
toxic or poisonous chemicals or their precursors; (B) a disease
organism, or; (C) radiation or radioactivity." [^32]

Even though the provisions of SARA Title III were not originally
designed for the intentional use of nuclear, chemical, biological and
explosive/incendiary agents by terrorists, the structure established by
the law and regulations created the hazard communication, emergency
planning and response system used to manage incidents involving
hazardous materials.

Within health care facilities, the foundation upon which a capability to
decontaminate patients can be built is the Hazard Communication and
Hazardous Waste Management Program(s).

But, as a recent Institute of Medicine report (see Appendix A) so
clearly describes, hospital preparedness for persons contaminated with
chemical and biological agents as a result of terrorism requires more
research and development. Many gaps exist \~ from the ability to
recognize and/or detect agents; what level of personal protective
equipment (PPE) is adequate; and how much decontamination is sufficient,
etc.

References:

## Government Regulations

1\. Department of Veterans Affairs, VA Directive 7700[, Occupational
Safety and Health]{.underline}, 7/8/98

2\. Department of Veterans Affairs, VA Directive 0320[, Emergency
Preparedness Planning]{.underline}, 1999.

3\. Department of Veterans Affairs, VHA Directive 99-011, [Emergency
Planning and Community Right-To-Know Program]{.underline}, 3/25/99

4\. Department of Veterans Affairs, VHA Directive 98-011[, Management of
Hazardous Chemicals]{.underline}, 2/19/98

5\. Department of Veterans Affairs, VHA Directive 0320.1, [Emergency
Medical Preparedness]{.underline}, 1997.

6\. Department of Veterans Affairs, Richard L. Roudebush VA Medical
Center, MCM Number: 001S-13, [Hazard Communication Program]{.underline},
8/18/99

7\. Department of Veterans Affairs, Richard L. Roudebush VA Medical
Center, MCM Number: 001S-20, [Hazardous Waste Management
Program]{.underline}, 8/17/99

8\. Department of Labor, Occupational Safety and Health Administration
regulations:

a\. 29 CFR 1910.120[, Hazardous Waste Operations and Emergency
Response]{.underline}

b\. 29 CFR 1910.1020, [Access to Employee Exposure and Medical
Records]{.underline}

c\. 29 CFR 1926.65, [Hazardous Waste Operations and Emergency
Response]{.underline}

d\. 29 CFR 1926.65 Appendix C, [Compliance Guidelines]{.underline}

e\. 29 CFR 1910.134, [Respiratory Protection]{.underline}

f\. 29 CFR 1910.134 Appendix A, [Fit Testing]{.underline}

g\. 29 CFR 1910.134 Appendix B-1, [User Seal Check
Procedures]{.underline}

h\. Respirator Change Out Schedule

## Publications

9\. Department of Labor, Occupational Safety and Health Administration,
[Interpretations of regulations]{.underline}.

10\. Institute of Medicine, [Chemical and Biological Terrorism: Research
and Development to Improve Civilian Medical Response]{.underline}

a\. Executive Summary

b\. Personal Protective Equipment

c\. Patient Decontamination and Mass Triage

11\. Health and Safety Management Program, [Hazmat: Managing the
Incident]{.underline}, Fire Protection Publications.

12\. Hazmat, Cox, RD

13\. Hazardous Materials: Disaster Medical Planning and Response[,
Journal of the American Medical Association]{.underline}, Levitin, HW
and Siegelson, HJ

14\. Decontamination and Management of Hazardous Materials Exposure
Victims in the Emergency Department, [Annals of Emergency
Medicine]{.underline}, April, 1994, 23(4), 761-770

15\. Emergency Department Response to Hazardous Materials Incidents,
[Emergency Medicine Clinics of North America]{.underline}, May 1994,
12(2), 461-481

16\. Department of Health and Human Services, Centers for Disease
Control and Prevention (CDC), [CDC Recommendations for Civilian
Communities Near Chemical Weapons Depots: Guidelines for Medical
Preparedness: Notice]{.underline}

17\. Department of Health and Human Services, Centers for Disease
Control and Prevention, Agency for Toxic Substances and Disease
Registry.

Chemical and Biological Terrorism: Research and Development to Improve
Civilian Medical Response

Exerpted from the Executive Summary

The Institute of Medicine, in collaboration with the Committee on Life
Sciences was asked by the Department of Health and Human Services,
Office of Emergency Preparedness to:

-   Collect and assess existing research, development and technology
    information on detecting potential chemical and biological agents
    and protecting and treating both the targets of attack and the
    health care providers, and

-   Provide specific recommendations for priority research and
    development

The report included eight recommendations, six of which are particularly
relevant to this discussion. They include:

-   Pre-Incident Communication and Intelligence

-   Personal Protective Equipment

-   Detection and Measurement of Chemical and Biological Agents

-   Mass Casualty Decontamination and Triage Procedures

-   Prevention, Assessment and Treatment of Psychological Effects

-   Computer-related Tools for Training and Operations

# Pre-Incident Communication and Intelligence

The response of even the most well prepared medical facilities will be
markedly improved by advance notice by the law enforcement community.
The latter understandably fear compromising ongoing investigations, but
may not fully appreciate the substantial impact even very general
information about possible incidents can have in facilitating a rapid
and effective response by the medical community. Receipt of information
concerning a mass casualty event need not involve more than a few key
individuals who can review the organization's seldom used planned begin
to think about treatment options and where and how to obtain needed
antidotes and drugs, make hospital beds available on short notice, and
ensure adequate staffing levels.

Recommendation: *There needs to be a system in every State and major
metropolitan area to ensure that medical facilities, including the State
epidemiology office, receive information on actual, suspected and
potential terrorist activity.*

*Specific R&D needs:*

-   *A formal communications network between the intelligence community
    and the medical community.*

-   *A national mechanism for the distribution of clinical data to the
    intelligence and medical communities after an actual event or
    exercise.*

# Personal Protective Equipment

Personal Protective Equipment (PPE) refers to clothing and respiratory
apparatus designed to shield an individual from chemical, biological or
physical hazards. The "universal precautions" (gloves, gown, mask,
goggles, etc.) employed by medical personnel to prevent infections will
generally provide protection from the biologic agents under discussion,
but it is difficult to say with confidence which, if any, civilian
workers have suitable chemical PPE because the testing and certification
demanded by the Occupational Safety and Health Administration (OSHA) has
not, until very recently, involved military nerve agents or vesicants,
and military PPE that has been tested for protection against those
agents generally does not have the testing and certification that would
allow it use by civilian workers. Hospitals receive not only
field-decontaminated patients but also "walk-ins" who may have bypassed
field decontamination. Despite Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) standards calling for hospitals to have
hazardous materials (hazmat) plans and conduct hazmat training, two
recent reviews have suggested that most hospitals in the United States
are ill-prepared to treat chemically contaminated patients.

Recommendation: *The committee endorses continued testing of civilian
commercial products for suitability in incidents involving chemical
warfare agents, but research is still needed addressing the bulk weight
and heat-stress imposed by current protective suits; developing a
powered air respirator with greatly increased protection, and in
providing detailed guidance for hospitals on dermal and respiratory
protection.*

*Specific R&D needs:*

-   *Increased protection factors for respirators.*

-   *Protective suits with less bulk, less weight and less heat-stress.*

-   *Evaluation of the impact of occupational regulations governing use
    of personal protective equipment.*

-   *Uniform testing standards for protective suits for use in chemical
    agents incidents.*

-   *Guidelines for the selection and use of personal protective
    equipment in hospitals.*

-   *Alternatives to respirators for expedient use by the general
    public.*

# Detection and Measurement of Chemical and Biological Agents

Hazardous materials or "hazmat" teams are routinely equipped with a
variety of chemical detectors and monitoring kits, primarily employing
chemical-specific tests indicating only the presence or absence of a
suspected chemical or class of chemical. The most common detectors test
for pesticides, chlorine, and cyanide, but not specifically for
phosgene, vesicants or nerve agents. Although chemical tests, detectors
and monitors used by the military are commercially available for
civilian use, they have not been acquired by civilian organizations in
appreciable numbers.

Laboratory assays indicating exposure to cyanide and anticholinesterase
compounds such as nerve agents are known and available at many
hospitals, but there is no current test for mustard agents or other
vesicants. However, for all of these agents except mustard, individuals
receiving potentially lethal doses usually develop signs and symptoms
within a matter of minutes after exposure. Therefore, initial diagnosis
and treatment are likely to be based on observations of signs and
symptoms by the paramedic or other health care professionals on the
scene.

Real-time detection and measurement of biologic agents in the
environment is more daunting, even for the military because of the
number of agents to be distinguished, the complex nature of the agents
themselves, the myriad of similar microorganisms that are always present
in the environment, and the impracticality of providing real-time,
continuous monitoring at even a fraction of the sites of potential
concern. Few, if any, civilian organizations currently have, or can
easily obtain even a rudimentary capability in this area.

Some serological, immunological, and nucleic acid assays are available
for identifying all of the biologic agents being considered in this
report, and many hospitals and commercial laboratories have the
necessary equipment and expertise to perform these and similar assays.
However, these diseases are extremely rare in the United States and for
that reason, these laboratories do not perform these assays regularly.
It therefore seems unlikely that many labs will be immediately prepared
to conduct the specific analytical test needed to confirm the presence
of the agent, even when the attending physician is astute enough to ask
for the appropriate test.

Recommendation: *The civilian medical community must find ways to adapt
the many new and emerging detection capabilities to the spectrum of
chemical and biological warfare agents. Public safety and rescue
personnel, emergency medical personnel and medical laboratories all need
faster, simpler, cheaper, more accurate instrumentation for detecting
and identifying a wide spectrum of toxic substances, including but not
limited to military agents, in both the environment and in clinical
samples from patients. The committee therefore recommends adopting
military products in the short run and supporting basic research
necessary to adapt civilian commercial products whenever possible in the
long run.*

*Specific R&D needs:*

-   *Evaluation of current hazmat and EMS chemical detection equipment
    for ability to detect military warfare agents.*

-   *Miniaturized and less expensive chromatography/mass spectrometry
    technology for monitoring the environment within fixed medical
    facilities and patient transport vehicles.*

-   *Standard Operating Procedures for communicating chemical detection
    information from first responders to hazmat teams, EMS teams and
    hospitals.*

-   *Simple, rapid and inexpensive methods of determining exposure to
    chemical agents from clinical samples.*

-   *Faster, cheaper, and easier patient diagnostics that include rare
    potential bioterrorism agents.*

-   *Inexpensive or multipurpose biodetectors for environmental testing
    and monitoring.*

-   *Basic research on pathogenesis and microbial metabolism.*

-   *Scenario-specific testing of assay and detector performance.*

# Mass Casualty Decontamination and Triage Procedures

The removal of solid or liquid chemical agents from exposed individuals
is the first step in preventing severe injury or death. Civilian Hazmat
teams generally have basic decontamination plans in place, although
proficiency may vary widely. Very few teams are staffed, equipped or
trained for mass decontamination. Hospitals need to be prepared to
decontaminate patients, despite plans that call for field
decontamination of all patients before transport to hospitals. However,
few hospitals have formal decontamination facilities, even fewer have
dedicated outdoor facilities or an easy way of expanding their
decontamination operations in an event involving mass casualties.

Recommendation: *Research and development in decontamination and triage
should concentrate on operations research to identify methods and
procedures for triage and rapid, effective and inexpensive
decontamination of large groups of people, equipment and environments.*

*Specific R&D needs:*

-   *The physical layout, equipment and supply requirements for
    performing mass decon for ambulatory and non-ambulatory patients of
    all ages and health in the field and in the hospital.*

-   *A standardized patient assessment and triage process for evaluating
    contaminated patients of all ages.*

-   *Optimal solution for performing patient decon, including decon of
    mucous membranes and open wounds.*

-   *The benefit vs. the risk of removing patient clothing.*

-   *Effectiveness of removing agents from clothing by a showering
    process.*

-   *Showering time necessary to remove chemical agents.*

-   *Whether high pressure/low volume or low pressure/high volume spray
    is more appropriate for optimal cleaning of contaminated areas.*

-   *The best methodology to employ in determining if a patient is
    "clean," and*

-   *The psychological impact of undergoing decontamination on all age
    groups.*

# Prevention, Assessment and Treatment of Psychological Effects

Risks to victims and rescue and health care workers in such incidents
include not only physical injury, but also psychological trauma.
Research on post traumatic stress disorder (PTSD) has expanded far
beyond studies of Vietnam veterans in the last 20 years, and including a
few studies of large-scale industrial accidents, among them, chemical
spills. The latter studies have most often been epidemiological in
nature, focusing on sequelae rather than treatment methods and efficacy.
A technique intended to prevent PTSD, Critical Incident Stress
Debriefing (CISD) has gained wide acceptance among field emergency
workers, and it can be expected that local police, fire and emergency
medical units will be familiar with the process and the plans to use it.
Scientific evidence of its efficacy, however, is equivocal.

At the federal level, the National Disaster Medical System includes
special Disaster Medical Assistance Teams specializing in mental health,
and the Federal Emergency Management Agency funds the Crisis Counseling
Assistance and Training Program. Few practitioners have experience with
chemical and biological disasters, however, and fewer still are
knowledgeable about chemical and biological warfare agents.

Recommendation: *Educational materials on chemical and biological agents
are badly needed by both the general public and mental health
professionals.*

*Specific R&D needs:*

-   *Identify resource material on chemical and biological agents and
    enlist the help of mental health professional societies in
    developing a training program for mental health professionals.*

-   *Psychological screening methods for differentiating adjustment
    reactions after chem/bio attacks from more serious psychological
    illness.*

-   *Evaluation of techniques for preventing or ameliorating adverse
    psychological effects in emergency workers, victims and
    near-victims.*

-   *Agent-specific information on risk assessment, threat perception by
    individuals and groups, and on risk communication by public
    officials.*

# Computer-Related Tools for Training and Operations

This section of the report identifies relevant computer-related tools
and pertinent health effects information that could be used by medical
and other first responders to train regularly or use operationally to
enhance and sustain capabilities for identifying or managing chemical or
biological terrorist incidents. These tools will also decrease the need
for participation in large exercises that can be disruptive,
logistically complicated, expensive, and sometimes unproductive.

Recommendation: *The committee recommends support for computer software
R&D in three areas: event reconstruction from medical data; dispersion
prediction and hazard assessment, and decontamination and reoccupation
decisions.*

*Specific R&D needs:*

-   *Computer software for rapid reporting of unusual medical
    symptomatology to public health authorities and linking that data to
    both toxicological information and models of agent dispersion.*

-   *Examination and field testing of current, and proposed atmospheric
    dispersion models to determine which would be the most suitable for
    the emergency management community.*

-   *Models of other possible vectors of dispersion (e.g., water, food
    and transportation).*

-   *Customizable simulation software to provide interactive training to
    personnel involved in management of chemical and biological
    terrorism incidents.*

-   *Information on the chemical, physical and toxicological properties
    of the chemical and biological agents, in order to improve modeling
    of their environmental transport and fate and to better support
    recommendations on decontamination and reoccupation decisions.*
    [^33]

Appendix B

29 CFR 1910.120, HAZWOPER

Training Curriculum Guidelines (App. E)

C. Emergency response training.

Federal OSHA standards in 29 CFR 1910.120(q) are directed toward private
sector emergency responders. Therefore, the guidelines provided in this
portion of the appendix are directed toward that employee population.
However, they also impact indirectly through State OSHA or USEPA
regulations some public sector emergency responders. Therefore, the
guidelines provided in this

portion of the appendix may be applied to both employee populations.

States with OSHA state plans must cover their employees with regulations
at least as effective as the Federal OSHA standards. Public employees in
states without approved state OSHA programs covering hazardous waste
operations and emergency response are covered by the U.S. EPA under 40
CFR 311, a regulation virtually identical to Sec. 1910.120.

Since this is a non-mandatory appendix and therefore not an enforceable
standard, OSHA recommends that those employers, employees or volunteers
in public sector emergency response organizations outside Federal OSHA
jurisdiction consider the following criteria in developing their own
training programs. A unified approach to training at the community level
between emergency response organizations covered by Federal OSHA and
those not covered directly by Federal OSHA can help ensure an effective
community response to the release or potential release of hazardous
substances in the community.

a\. General considerations.

Emergency response organizations are required to consider the topics
listed in Sec. 1910.120(q)(6). Emergency response organizations may use
some or all of the following topics to supplement those mandatory topics
when developing their response training programs. Many of the topics
would require an interaction between the response provider and the
individuals responsible for the site where the response would be
expected.

\(1\) Hazard recognition, including:

\(A\) Nature of hazardous substances present,

\(B\) Practical applications of hazard recognition, including
presentations on biology, chemistry, and physics.

\(2\) Principles of toxicology, biological monitoring, and risk
assessment.

\(3\) Safe work practices and general site safety.

\(4\) Engineering controls and hazardous waste operations.

\(5\) Site safety plans and standard operating procedures.

\(6\) Decontamination procedures and practices.

\(7\) Emergency procedures, first aid, and self-rescue.

\(8\) Safe use of field equipment.

\(9\) Storage, handling, use and transportation of hazardous substances.

\(10\) Use, care, and limitations of personal protective equipment.

\(11\) Safe sampling techniques.

\(12\) Rights and responsibilities of employees under OSHA and other
related laws concerning right-to-know, safety and health, compensations
and liability.

\(13\) Medical monitoring requirements.

\(14\) Community relations.

b\. Suggested criteria for specific courses.

\(1\) First responder awareness level.

\(A\) Review of and demonstration of competency in performing the
applicable skills of 29 CFR 1910.120(q).

\(B\) Hands-on experience with the U.S. Department of Transportation\'s
Emergency Response Guidebook (ERG) and familiarization with OSHA
standard 29 CFR 1910.1201.

\(C\) Review of the principles and practices for analyzing an incident
to determine both the hazardous substances present and the basic hazard
and response information for each hazardous substance present.

\(D\) Review of procedures for implementing actions consistent with the
local emergency response plan, the organization\'s standard operating
procedures, and the current edition of DOT\'s ERG including emergency
notification procedures and follow-up communications.

\(E\) Review of the expected hazards including fire and explosions
hazards, confined space hazards, electrical hazards, powered equipment
hazards, motor vehicle hazards, and walking-working surface hazards.

\(F\) Awareness and knowledge of the competencies for the First
Responder at the Awareness Level covered in the National Fire Protection
Association\'s Standard No. 472, Professional Competence of Responders
to Hazardous Materials Incidents.

\(2\) First responder operations level.

\(A\) Review of and demonstration of competency in performing the
applicable skills of 29 CFR 1910.120(q).

\(B\) Hands-on experience with the U.S. Department of Transportation\'s
Emergency Response Guidebook (ERG), manufacturer material safety data
sheets, CHEMTREC/CANUTEC, shipper or manufacturer contacts, and other
relevant sources of information addressing hazardous substance

releases. Familiarization with OSHA standard 29 CFR 1910.1201.

\(C\) Review of the principles and practices for analyzing an incident
to determine the hazardous substances present, the likely behavior of
the hazardous substance and its container, the types of hazardous
substance transportation containers and vehicles, the types and
selection of the appropriate defensive strategy for containing the
release.

\(D\) Review of procedures for implementing continuing response actions
consistent with the local emergency response plan, the organization\'s
standard operating procedures, and the current edition of DOT\'s ERG
including extended emergency notification procedures and follow-up
communications.

\(E\) Review of the principles and practice for proper selection and use
of personal protective equipment.

\(F\) Review of the principles and practice of personnel and equipment
decontamination.

\(G\) Review of the expected hazards including fire and explosions
hazards, confined space hazards, electrical hazards, powered equipment
hazards, motor vehicle hazards, and walking-working surface hazards.

\(H\) Awareness and knowledge of the competencies for the First
Responder at the Operations Level covered in the National Fire
Protection Association\'s Standard No. 472, Professional Competence of
Responders to Hazardous Materials Incidents.

\(3\) Hazardous materials technician.

\(A\) Review of and demonstration of competency in performing the
applicable skills of 29 CFR 1910.120(q).

\(B\) Hands-on experience with written and electronic information
relative to response decision making including but not limited to the
U.S. Department of Transportation\'s Emergency Response Guidebook (ERG),
manufacturer material safety data sheets, CHEMTREC/CANUTEC, shipper or
manufacturer contacts, computer data bases and response models, and
other relevant sources of

information addressing hazardous substance releases. Familiarization
with OSHA standard 29 CFR 1910.1201.

\(C\) Review of the principles and practices for analyzing an incident
to determine the hazardous substances present, their physical and
chemical properties, the likely behavior of the hazardous substance and
its container, the types of hazardous substance transportation
containers and vehicles involved in the release, the appropriate
strategy for approaching release sites and containing the

release.

\(D\) Review of procedures for implementing continuing response actions
consistent with the local emergency response plan, the organization\'s
standard operating procedures, and the current edition of DOT\'s ERG
including extended emergency notification procedures and follow-up
communications.

\(E\) Review of the principles and practice for proper selection and use
of personal protective equipment.

\(F\) Review of the principles and practices of establishing exposure
zones, proper decontamination and medical surveillance stations and
procedures.

\(G\) Review of the expected hazards including fire and explosions
hazards, confined space hazards, electrical hazards, powered equipment
hazards, motor vehicle hazards, and walking-working surface hazards.

\(H\) Awareness and knowledge of the competencies for the Hazardous
Materials Technician covered in the National Fire Protection
Association\'s Standard No. 472, Professional Competence of Responders
to Hazardous Materials Incidents.

\(4\) Hazardous materials specialist.

\(A\) Review of and demonstration of competency in performing the
applicable skills of 29 CFR 1910.120(q).

\(B\) Hands-on experience with retrieval and use of written and
electronic information relative to response decision making including
but not limited to the U.S. Department of Transportation\'s Emergency
Response Guidebook (ERG), manufacturer material safety data sheets,
CHEMTREC/CANUTEC, shipper or manufacturer contacts, computer data bases
and response models, and other relevant sources of information
addressing hazardous substance releases.

Familiarization with OSHA standard 29 CFR 1910.1201.

\(C\) Review of the principles and practices for analyzing an incident
to determine the hazardous substances present, their physical and
chemical properties, and the likely behavior of the hazardous substance
and its container, vessel, or vehicle.

\(D\) Review of the principles and practices for identification of the
types of hazardous substance transportation containers, vessels and
vehicles involved in the release; selecting and using the various types
of equipment available for plugging or patching transportation
containers, vessels or vehicles; organizing and directing the use of
multiple teams of hazardous material technicians and selecting the
appropriate strategy for approaching release sites and containing or
stopping the release.

\(E\) Review of procedures for implementing continuing response actions
consistent with the local emergency response plan, the organization\'s
standard operating procedures, including knowledge of the available
public and private response resources, establishment of an incident
command post, direction of hazardous material technician teams, and
extended emergency notification procedures and follow-up communications.

\(F\) Review of the principles and practice for proper selection and use
of personal protective equipment.

\(G\) Review of the principles and practices of establishing exposure
zones and proper decontamination, monitoring and medical surveillance
stations and procedures.

\(H\) Review of the expected hazards including fire and explosions
hazards, confined space hazards, electrical hazards, powered equipment
hazards, motor vehicle hazards, and walking-working surface hazards.

\(I\) Awareness and knowledge of the competencies for the Off-site
Specialist Employee covered in the National Fire Protection
Association\'s Standard No. 472, Professional Competence of Responders
to Hazardous Materials Incidents.

\(5\) Incident commander.

The incident commander is the individual who, at any one time, is
responsible for and in control of the response effort. This individual
is the person responsible for the direction and coordination of the
response effort. An incident commander\'s position should be occupied by
the most senior, appropriately trained individual present at the
response site. Yet, as necessary and appropriate by the level of
response provided, the position may be occupied by many individuals
during a particular response as the need for greater authority,
responsibility, or training increases. It is possible for the first
responder at the awareness level to assume the duties of incident
commander until a more senior and appropriately trained individual
arrives at the response site.

Therefore, any emergency responder expected to perform as an incident
commander should be trained to fulfill the obligations of the position
at the level of response they will be providing including the following:

\(A\) Ability to analyze a hazardous substance incident to determine the
magnitude of the response problem.

\(B\) Ability to plan and implement an appropriate response plan within
the capabilities of available personnel and equipment.

\(C\) Ability to implement a response to favorably change the outcome of
the incident in a manner consistent with the local emergency response
plan and the organization\'s standard operating procedures.

\(D\) Ability to evaluate the progress of the emergency response to
ensure that the response objectives are being met safely, effectively,
and efficiently.

\(E\) Ability to adjust the response plan to the conditions of the
response and to notify higher levels of response when required by the
changes to the response plan.

\[54 FR 9317, Mar. 6, 1898, as amended at 55 FR 14073, Apr. 13, 1990; 56
FR 15832, Apr. 18, 1991; 59 FR 43268, Aug. 22, 1994; 61 FR 9227, March
7, 1996\]

Appendix C

29 CFR 1910.132, Personal Protective Equipmrent

General Requirements (Training)

\(f\) Training.

(f)(1) The employer shall provide training to each employee who is
required by this section to use PPE. Each such employee shall be trained
to know at least the following:

(f)(1)(i) When PPE is necessary;

(f)(1)(ii) What PPE is necessary;

(f)(1)(iii) How to properly don, doff, adjust, and wear PPE;

(f)(1)(iv) The limitations of the PPE; and,

(f)(1)(v) The proper care, maintenance, useful life and disposal of the
PPE.

(f)(2) Each affected employee shall demonstrate an understanding of the
training specified in paragraph (f)(1) of this section, and the ability
to use PPE properly, before being allowed to perform work requiring the
use of PPE.

(f)(3) When the employer has reason to believe that any affected
employee who has already been trained does not have the understanding
and skill required by paragraph (f)(2) of this section, the employer
shall retrain each such employee. Circumstances where retraining is
required include, but are not limited to, situations where:

(f)(3)(i) Changes in the workplace render previous training obsolete; or

..1910.132(f)(3)(ii)

(f)(3)(ii) Changes in the types of PPE to be used render previous
training obsolete; or

(f)(3)(iii) Inadequacies in an affected employee\'s knowledge or use of
assigned PPE indicate that the employee has not retained the requisite
understanding or skill.

(f)(4) The employer shall verify that each affected employee has
received and understood the required training through a written
certification that contains the name of each employee trained, the
date(s) of training, and that identifies the subject of the
certification.

\(g\) Paragraphs (d) and (f) of this section apply only to 1910.133,
1910.135, 1910.136, and 1910.138. Paragraphs (d) and (f) of this section
do not apply to 1910.134 and 1910.137.

\[39 FR 23502, June 27, 1974, as amended at 59 FR 16334, April 6, 1994;
59 FR 33910, July 1, 1994; 59 FR 34580, July 6, 1994\]

Appendix D

29 CFR 1910.1200, Hazard Communication Standard

Requirements of Training Programs

..1910.1200(h)

\(h\) \"Employee information and training.\"

(h)(1) Employers shall provide employees with effective information and
training on hazardous chemicals in their work area at the time of their
initial assignment, and whenever a new physical or health hazard the
employees have not previously been trained about is introduced into
their work area. Information and training may be designed to cover
categories of hazards (e.g., flammability, carcinogenicity) or specific
chemicals. Chemical-specific information must always be available
through labels and material safety data sheets.

(h)(2) \"Information.\" Employees shall be informed of:

(h)(2)(i) The requirements of this section;

(h)(2)(ii) Any operations in their work area where hazardous chemicals
are present; and,

(h)(2)(iii) The location and availability of the written hazard
communication program, including the required list(s) of hazardous
chemicals, and material safety data sheets required by this section.

(h)(3) \"Training.\" Employee training shall include at least:

(h)(3)(i) Methods and observations that may be used to detect the
presence or release of a hazardous chemical in the work area (such as
monitoring conducted by the employer, continuous monitoring devices,
visual appearance or odor of hazardous chemicals when being released,
etc.);

(h)(3)(ii) The physical and health hazards of the chemicals in the work
area;

(h)(3)(iii) The measures employees can take to protect themselves from
these hazards, including specific procedures the employer has
implemented to protect employees from exposure to hazardous chemicals,
such as appropriate work practices, emergency procedures, and personal
protective equipment to be used; and,

(h)(3)(iv) The details of the hazard communication program developed by
the employer, including an explanation of the labeling system and the
material safety data sheet, and how employees can obtain and use the
appropriate hazard information.

[^1]: Memorandum, EMSHG Headquarters, November 22, 1999.

[^2]: VA Directive 99-011

[^3]: See OSHA \_\_ and VA policy 7700.

[^4]: Definition from OSHA,

[^5]: VHA Directive 99-011: "When SARA Title III was passed in 1986,
    Federal agencies and activities were not required to comply.
    However, as a result of the Federal facilities Compliance Act of
    1992 and Executive Order 12856 of 1993, all Federal agencies and
    facilities are required to comply with the provisions of SARA Title
    III, state and local environmental regulations, and actively
    participate in emergency planning activities."

[^6]: Richard L. Roudebush VA Medical Center, MCM 001S-13, Hazard
    Communication Program Policy.

[^7]: Richard L. Roudebush VA Medical Center, MCM 001S-20, Hazardous
    Waste Management Program.

[^8]: OSHA Interpretive Letter, August 1, 1990.

[^9]: OSHA Interpretative Letter, June 7, 1991.

[^10]: OSHA Standard 1910.120(a)(2)(iv)(3).

[^11]: Hospitals and HAZWOPER, OSHA response to a letter from D.
    Bennett, 06-07-91.

[^12]: OSHA Interpretive Letter, October 21, 1992

[^13]: OSHA, Interpretation

[^14]: Hazardous Materials: Disaster Medical Planning and Response, p.
    333-334.

[^15]: Richard L. Roudebush VA Medical Center, MCM Number 11-05.

[^16]: Federal Response Plan for Public Law 93-288, as amended,
    Occupational Safety and Health Annex, page SH-2.

[^17]: Cox, RD, Hazmat.

[^18]: OSHA Interpretive Letter, June 7, 1991.

[^19]: OSHA Interpretive Letter, March 10, 1999.

[^20]: OSHA Interpretive Letter, June 7, 1991.

[^21]: Hospital Preparedness for Receiving Contaminated Victims, OSHA
    response to a letter from C.O. Toole, 10-21-92.

[^22]: OSHA Interpretive Letter, October 27, 1992.

[^23]: OSHA 29 CFR 1910.120)q)

[^24]: Hazardous Waste Operations and Emergency Response: A Closeup Look
    at Training, Seymour.

[^25]: OSHA Interpretive Letter, October 21, 1992.

[^26]: OSHA Interpretive Letter, December 2, 1991

[^27]: 29 CFR 1910.132.

[^28]: OSHA Interpretive Lretter, December 9, 1996.

[^29]: OSHA Policy Memorandum, 1994.

[^30]: 29 CFR 1910.132

[^31]: OSHA Interpretive Letter, August 5, 1993.

[^32]: Nunn-Lugar-Domenici Act, as referenced by the First Annual Report
    to the President and Congress by the Advisory Panel to Assess
    Domestic Response Capabilities for Terrorism Involving Weapons of
    Mass Destruction (Draft), 12/15/99.

[^33]: Chemical and Biological Terrorism: Research and Development to
    Improve Civilian Medical Response, Institute of Medicine, national
    Research Council,