**Bloodborne Pathogens Exposure Control Plan**

**U.S. Department of State**

**Medical Services**

.\
\
**POLICY**

The U.S. Department of State, Medical Services (M/MED) is committed to
providing a safe and healthful work environment for our entire staff. In
pursuit of this goal, the following exposure control plan (ECP) is
provided to eliminate or minimize occupational exposure to bloodborne
pathogens (BBP) in accordance with OSHA standard 29 *CFR* 1910.1030,
\"Occupational Exposure to Bloodborne Pathogens.\"\
\
The BBP exposure control plan is a key document to assist our
organization in implementing and ensuring compliance with the standard,
thereby protecting our employees. This plan includes:

-   Determination of employee exposure

-   Implementation of various methods of exposure control, including:

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-   Universal precautions

-   Engineering and work practice controls

-   Personal protective equipment

-   Housekeeping

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-   Hepatitis B vaccination

-   Post-exposure evaluation and follow-up

-   Communication of hazards to employees and training

-   Recordkeeping

-   Procedures for evaluating circumstances surrounding exposure
    incidents

Implementation methods for these elements of the standard are discussed
in the subsequent pages of this BBP exposure control plan.

Contractor employees must also comply with the OSHA standard. Contract
language must specify that the employer must ensure that employees
receive BBP training. It is MED's responsibility to ensure that contract
employees understand where BBP exposure may occur.

**PROGRAM ADMINISTRATION**

-   All overseas and domestic health units, clinics, and laboratories
    are responsible for implementing this plan. The MED/DASHO Industrial
    Hygienist (IH) will maintain, review, and update the plan at least
    annually, and whenever necessary to include new or modified tasks
    and procedures. The IH will ensure that the exposure control plan is
    available to employees and make the written plan available to
    employees and OSHA and NIOSH representatives. Contact phone number:
    202-663-1355.

-   Those employees who are determined to have occupational exposure to
    blood or other potentially infectious materials (OPIM) must comply
    with the procedures and work practices outlined in this exposure
    control plan.

-   Each overseas and domestic health unit, clinic, and laboratory will
    provide and maintain all necessary personal protective equipment
    (PPE), engineering controls (e.g., sharps containers), labels, and
    red bags as required by the standard and will ensure that adequate
    supplies of the aforementioned equipment are available in the
    appropriate sizes.

-   The head of each overseas and domestic health unit, clinic, and
    laboratory is responsible for ensuring that all medical actions
    required by the standard are performed and that appropriate employee
    health and OSHA records are maintained.

-   RMOs/FSHPs are responsible to ensure that this BBP exposure control
    plan is implemented at their posts and that employees in health
    units, clinics, and laboratories under their purview receive initial
    and yearly training.

-   The Chief of MED/DASHO/OH is responsible to ensure that appropriate
    training programs are available to all personnel in this program.
    Contact phone number: 202-663-3662.

-   The Director of MED/FSHP is responsible for documentation of
    training, recordkeeping, and tracking of the annual training
    requirement. Contact phone number: 202-663-1647.

**EMPLOYEE EXPOSURE DETERMINATION**

Each facility or department is required to perform an employee exposure
determination. Appendix C provides a guidance outline for doing this
determination. The exposure determination must be reviewed at least
annually and updated if necessary. If an employee's job changes in the
interim, the exposure determination must be reviewed at that time.

NOTE: Part-time, temporary, contract and per diem employees are covered
by the bloodborne pathogens standard. These employees are to be included
in the determination.\
\
**METHODS OF IMPLEMENTATION AND CONTROL**\
\
**Universal Precautions**: All employees will use universal
precautions.\
\
**Exposure Control Plan**: Employees covered by the bloodborne pathogens
standard will receive an explanation of this BBP exposure control plan
during their initial training session. It will also be reviewed in their
annual refresher training. All employees can review this plan at any
time during their work shifts by viewing it online on the MED web page
or by requesting it from their supervisors. Supervisors must supply
copies within 15 days of the request.\
\
The head of the health unit or department is responsible for reviewing
and updating jobs and tasks annually or more frequently if necessary to
reflect any new or modified tasks and procedures that affect
occupational exposure and to reflect new or revised employee positions
with occupational exposure. An individual within the unit or department
may be assigned to have this responsibility.\
\
**Engineering Controls and Work Practices**: Engineering controls are
controls that isolate or remove the bloodborne pathogen hazard from the
workplace. E.g., sharps disposal containers, self-sheathing needles, and
safer medical devices such as sharps with engineered sharps injury
protections. Engineering controls and work practice controls will be
used to prevent or minimize exposure to bloodborne pathogens.

The supervisor of each health unit or department will list specific
engineering controls and work practice controls to be used. This is best
done along with employee exposure determination tasks. Where
occupational exposure remains after institution of these controls,
personal protective equipment must also be used.\
\
The Supervisor of each health unit or department will also assign an
individual or individuals to maintain, inspect, dispose, and replace
sharps disposal containers. These containers are to be inspected,
maintained, and disposed whenever necessary to prevent overfilling.\
\
MED/DASHO/OH will monitor the need for changes in engineering controls
and work practices through review of incidents relating to BBPs,
information provided by RMTs, FSHPs, and RMOs from observing activities
in the field, employee input, and review of new product offerings. New
product offerings will be monitored by reviewing pertinent
manufacturers' literature, information provided in professional
publications, and equipment displays at conferences. Guidance will be
provided to posts and departments.\
\
Both supervisors and employees are involved in this process by
discussing new product applications in the workplace and by testing to
see if these new products provide better protection than currently used
products.

Below are some rules to follow in this regard:

-   Inspect engineering controls and maintain or replace them on a
    regular schedule to ensure their effectiveness.

-   Hand washing facilities must be readily accessible. Employees must
    wash their hands immediately or as soon as feasible after removal of
    gloves or other personal protective equipment. In cases of contact
    with unprotected body areas with blood or other potentially
    infectious materials, the skin areas should be washed with soap and
    water, and mucous membranes flushed with water, as soon as is
    feasible. When antiseptic hand cleansers or towelettes are used,
    wash hands with soap and running water as soon as feasible.

-   Do not eat, drink, smoke or apply cosmetics or lip balm, or handle
    contact lenses in work areas, where there is reasonable likelihood
    of occupational exposure.

-   Keep food and drink out of refrigerators, freezers, shelves,
    cabinets, or counters where blood or other potentially infectious
    materials are kept.

-   Perform all procedures involving blood or other potentially
    infectious materials (OPIM) in such a manner as to minimize
    splashing, spraying, spattering, and generation of droplets of these
    substances.

-   Do not pipette/suction any material by mouth.

-   Place specimens of blood or other potentially infectious materials
    in a container that prevents leakage during collection, handling,
    storage, transport, or shipping. Package specimens according to
    defined shipping and transport procedures.

-   Never recap, bend, break, or remove contaminated needles and other
    contaminated disposable sharps unless it can be demonstrated that no
    alternative is feasible or that such action is required by a
    specific medical procedure. If required, recapping or needle removal
    must be accomplished through the use of a mechanical device or a
    one-handed (scoop) technique. Shearing or breaking needles is
    prohibited.

-   Place contaminated reusable sharps in an appropriate container
    immediately or as soon as possible after use. This container shall
    be puncture resistant, labeled as "biohazard," and leak-proof on the
    sides and bottom. Do not store or process contaminated reusable
    sharps in a manner that requires reaching by hand into the container
    where these sharps have been placed.

-   Discard contaminated needles and sharp disposable instruments in
    closable, puncture resistant containers that are leak proof on sides
    and bottom. The containers should be red or labeled "biohazard" and
    be easily accessible where needed, maintained upright, and not
    allowed to be overfilled. Contaminated items such as broken glass,
    scalpel blades (removed from reusable handles with forceps) and
    other sharps should also be discarded in containers as described
    above.

-   Prior to servicing or shipping, decontaminate equipment that may
    have become contaminated with blood or other potentially infectious
    material.

**Personal Protective Equipment (PPE)**: Personal protective equipment
provides a barrier to prevent skin and mucous membrane exposure when
contact with blood or other potentially infectious materials is
anticipated after institution of work practice controls. When there is
occupational exposure, the appropriate PPE is that which does not permit
blood, or other potentially infectious materials, to pass through to or
reach the employee's work clothes or skin under normal conditions of use
and for the duration of time which the protective equipment will be
used. PPE is provided to our employees at no cost to them. Training in
the use of the appropriate PPE for specific tasks or procedures is
provided by supervisors or by knowledgeable, fully-trained employees.

*Gloves* -- Wear gloves when it can be reasonably anticipated that there
will be hand contact with blood, other potentially infectious materials,
mucous membranes, and non-intact skin; when performing vascular access
procedures and when handling or touching contaminated items or surfaces.
Replace disposable (single use) gloves such as surgical or examination
gloves as soon as practical when contaminated or as soon as feasible if
they are torn, punctured, or when their ability to function as a barrier
is compromised. Never wash disposable gloves or decontaminate them for
re-use. Utility gloves (rubber or heavy latex) may be decontaminated for
re-use if the integrity of the glove is not compromised. However,
discard them if they are cracked or torn and their ability to function
as a barrier is compromised.

*Face Protection* -- Wear masks in combination with eye protection
devices, such as goggles or glasses with solid side shields or chin
length face shields whenever splashes, spray, splatter or droplets of
blood or other potentially infectious materials may be generated and
eye, nose, or mouth contamination can be reasonably anticipated.

*Gowns* -- Wear gowns, aprons, laboratory coats, or other protective
body clothing in occupational exposure situations. The type and
characteristics shall depend on the task and degree of exposure
anticipated.

*General PPE Precautions* -

-   Wash hands immediately or as soon as feasible after removing gloves
    or other PPE.

-   Remove any garment contaminated by blood or other potentially
    infectious (OPIM) immediately or as soon as feasible, in such a way
    as to avoid contact with the outer surface.

-   Properly discard used PPE. Each location/department will train
    employees on appropriate containers for storage, laundering,
    decontamination, or disposal.

-   Remove PPE before leaving the work area

Each MED location/department is to have a procedure for handling used
PPE, e.g., cleaning decontamination, storage, disposal, etc.

Below is a table with suggested PPE for specific activities.

  ------------------------------------- ---------------------------------
  ACTIVITY                              PPE

  Examination of patients with open     Gloves
  lesions                               

  Digital or manual examination of      Gloves
  mucous membrane areas, i.e., mouth,   
  vagina, rectum                        

  Assisting with pap smears and placing Gloves
  slides in container                   

  Inoculations or administering         (Wash hands with soap & water or
  injections including intradermal skin use an alcohol-based hand rub)
  tests                                 

  Measuring temperature or blood        Gloves are not required
  pressure                              

  Phelbotomy, IV administration         Gloves

  Wound care, dressing changes          Gloves

  Excision of lesions or biopsies       Gloves

  Sigmoidoscopy                         Glove, gown or apron if splashing
                                        is anticipated

  Handling of regulated waste, cleaning Gloves
  blood/body fluid spills, and handling 
  contaminated instruments              

  Cleaning of sigmoid scopes and        Gloves, protective face shield
  aspiration pumps                      and apron if splashing is
                                        anticipated

  Performing laboratory tests           Gloves, protective face shield if
                                        splashing is anticipated
  ------------------------------------- ---------------------------------

**Sanitation:** The workplace must be kept clean and sanitary.
Contaminated work surfaces must be decontaminated with a disinfectant
upon completion of procedures or when contaminated by splashes, spills,
or contact with blood or other potentially infectious materials. Work
surfaces shall be disinfected at the end of the work shift if the
surface may have become contaminated since the last cleaning. Waste cans
and pails must be inspected and decontaminated on a regularly scheduled
basis. Broken glass shall be cleaned up by mechanical means, such as
with a brush or tongs; never pick up broken glass with hands, even when
wearing gloves. [Note]{.underline}: The Center for Disease Control (CDC)
recommends that a 10% bleach solution be used for sterilization. A 10%
solution corresponds to 1 ½ cups of household bleach per gallon of
water, or 1 part bleach to 9 parts water. This solution should be made
up immediately prior to each use. Once mixed, this bleach solution will
begin deteriorating and should be discarded after 24 hours.

-   Handling and disposal of contaminated needles, scalpels, broken
    glass and other sharps

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-   Never recap, bend, break, or remove contaminated needles and other
    contaminated disposable sharps unless it can be demonstrated that no
    alternative is feasible or that such action is required by a
    specific medical procedure. If required, recapping or needle removal
    must be accomplished through the use of a mechanical device or a
    one-handed (scoop) technique. Shearing or breaking needles is
    prohibited.

-   Immediately or as soon as feasible, discard contaminated needles and
    sharp disposable instruments in closable, puncture resistant
    containers that are leak proof on sides and bottom. The containers
    should be red or labeled "biohazard" and be easily accessible where
    needed, maintained upright, and not allowed to be overfilled.
    Similarly, contaminated items such as broken glass, scalpel blades
    (removed from reusable handles with forceps) and other sharps should
    be discarded in containers as described above.

    -   When an approved sharps container is seventy-five percent full,
        verify that it is labeled as "biohazard," seal it, have a Diack
        sticker (or similar indicator of proper sterilization) attached
        to it, and autoclave it. Once sterilized, the container should
        be disposed of using approved procedures (buried in a designated
        landfill or incinerated). If an autoclave is unavailable,
        disinfect using the bleach solution described below by pouring
        the solution into the container, and seal. The container should
        be allowed to sit for 24 hours before the solution can be
        drained off, the container and contents sealed, and then
        disposed as described above. Do not empty and reuse the
        container.

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-   Handling reusable instruments, including sharps

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-   Contaminated reusable instruments, including sharps, should be
    processed in a way that ensures safe handling. Wear gloves when
    handling and cleaning contaminated instruments and do not reach by
    hand into containers where reusable sharps may have been placed. Use
    forceps or a similar instrument. Usually, reusable instruments are
    placed in an approved disinfectant solution (an EPA approved
    chemical "sterilant" or the bleach solution described above) for at
    least 15 minutes, after which they can be scrubbed in soap and
    water, rinsed, re-wrapped, and sterilized for reuse.

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-   Handling and disposal of regulated waste other than sharps

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-   See Appendix B, Medical Waste Policy. Regulated waste shall be
    placed in closable, leak proof, puncture resistant, autoclavable
    plastic bags which are red or labeled "biohazard." Such waste should
    be incinerated or decontaminated by autoclave or by chemical
    disinfection.

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-   Cleaning procedures for spills of blood or other potentially
    infectious materials

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-   Wear suitable gloves

-   Use a mechanical device such as forceps to pick up pieces of glass
    or other particulate matter. Place these materials directly in the
    appropriate bag or container used for contaminated sharps or
    regulated waste.

-   Carefully remove the body fluids from the spill surface with gauze
    sponges. When each sponge is saturated replace it with a new one. Do
    not wring out the fluid. Place all soiled sponges in the regulated
    waste container.

-   Once the body fluids have been removed from the area, apply an EPA
    approved chemical "sterilant" or bleach solution to decontaminate
    the area. If a bleach solution is used, it can be prepared by mixing
    1 and a half cups of household bleach per gallon of water, or 1 part
    bleach to 9 parts water. Make a fresh bleach solution for each use.
    Once mixed, this bleach solution will start deteriorating and should
    not be kept for more than 24 hours. The material being sprayed or
    poured over should be thoroughly drenched, in order to maximize
    penetration of the material by the sterilizing solution.

-   Note: It is strongly recommended that carpeting not be used in
    patient care areas, because of the difficulty in sanitizing these
    surfaces.

**Laundry:** If contaminated articles are to be laundered, the MED
location/department will develop procedures on handling and storing of
the articles and make employees aware of the procedures. A person
responsible for laundering should be named.\
\
The following laundering requirements must be met:

-   Handle contaminated laundry as little as possible, with minimal
    agitation

-   Place wet, contaminated laundry in leak-proof, labeled or
    color-coded containers before transport. Use either red bags or bags
    marked with the biohazard symbol for this purpose.

-   The MED location/department is to determine appropriate PPE to wear
    when handling and/or sorting contaminated laundry, depending on the
    hazard posed.

**Labels**: Each MED location/department is to determine what equipment,
containers, or articles are to be labeled and the type of label to be
used. This includes red-bagging, which is considered a means for
identifying contaminated items. Employees are to be aware of the
labeling and bagging procedure. A specific individual may be assigned to
ensure that warning labels are affixed or red bags are used as required.

Employees are to notify their supervisors if they discover regulated
waste containers, refrigerators containing blood or other potentially
infectious material, contaminated equipment, etc., without proper
labels.

**HEPATITIS B VACCINATION**

Employee BBP training will include information on hepatitis B
vaccinations, addressing safety, benefits, efficacy, methods of
administration, and availability.\
\
The hepatitis B vaccination will be provided at no cost after initial
employee training and within 10 days of initial assignment to all
employees identified in the exposure determination section of this plan.
Vaccination is encouraged unless: 1) documentation exists that the
employee has previously received the series; 2) antibody testing reveals
that the employee is immune; or 3) medical evaluation shows that
vaccination is contraindicated. (Note: Hepatitis B immunoglobulin will
also be provided at no cost if needed.)\
\
However, if an employee declines the vaccination, the employee must sign
a declination form. (See Appendix D for the form.) Employees who decline
may request and obtain the vaccination at a later date at no cost.
Documentation of refusal of the vaccination will be kept with the
employee's medical record.\
\
A MED medical professional will evaluate an employee's suitability for a
hepatitis B vaccination. Following the medical evaluation, a copy of the
health care professional\'s written opinion will be obtained and
provided to the employee within 15 days of the completion of the
evaluation. It will be limited to whether the employee requires the
hepatitis vaccine and whether the vaccine was administered. A record of
the immunization will be kept in the employee's medical record.

**POST-EXPOSURE EVALUATION AND FOLLOW-UP**

An exposure incident is defined as a specific eye, mouth, other mucous
membrane, non-intact skin, or parenteral (percutaneous inoculation)
contact with blood or other potentially infectious materials, that
results from the performance of an employee's duties.

Immediately following an exposure incident, the employee must follow
certain procedures. In cases of contact of unprotected body areas with
blood or other potentially infectious materials, wash skin areas with
soap and water and flush mucous membranes with water.

If the exposure incident occurs [overseas,]{.underline} the employee
should notify the Regional Medical Officer or the Foreign Service Health
Practitioner responsible for the Health Unit, who will direct a
confidential medical evaluation and follow-up of the exposure incident.
The employee will require services from an outside provider if the DOS
healthcare professional is not available. To document the incident, the
employee along with the supervisor is required to complete form DS-1663,
Report of Mishap, and immediately provide a copy to the Post
Occupational Safety and Health Officer (POSHO) who will send it to SHEM.
See <http://obo.state.gov/opssaf-shem/mishaps.htm>. SHEM will provide a
copy of the DS-1663 to MED/DASHO/OH for tracking purposes. The form
CA-1, Notice of Traumatic Injury and Claim for Continuation of
Pay/Compensation, should also be completed and submitted to HR; it will
cover necessary expenses. See
<http://hrweb.hr.state.gov/prd/hrweb/er/employment/workcomp/upload/wc-prep-kit.pdf>.
In addition, the MED "Medical Incident" form shown in Appendix F must be
completed as part of the incident documentation and follow-up.

If the exposure incident occurs in Department of State Health Units in
[Washington, DC]{.underline}, the employee should notify his/her
immediate supervisor and report to the Director of Occupational Health.
The Director of Occupational Health is the designated healthcare
professional who will direct a confidential medical evaluation and
follow-up for the exposure incident. Complete form DS-1663, Report of
Mishap, and send to DESD. DESD will provide a copy of the DS-1663 to
MED/DASHO/OH for tracking purposes. See
<http://aoprfms.a.state.gov/index.cfm?fuseaction=public.display&id=c88ca9c8-b28e-4e89-9f11-563f0db73a03>.
Also submit the form CA-1, Notice of Traumatic Injury and Claim for
Continuation of Pay/Compensation to HR. As for overseas incidents, the
MED "Medical Incident" form shown in Appendix F must also be completed
as part of the incident documentation and follow-up.

Following initial first aid (clean the wound, flush eyes or other mucous
membrane, etc.), the following activities will be performed:

-   Document the routes of exposure and how the exposure occurred.

-   Identify and document the source individual (unless the employer can
    establish that identification is infeasible or prohibited by state
    or local law).

-   Obtain consent and make arrangements to have the source individual
    tested as soon as possible to determine HIV, HCV, and HBV
    infectivity; document that the source individual\'s test results
    were conveyed to the employee\'s health care provider. (Note that
    the source individual is not obligated to provide consent.)

-   If the source individual is already known to be HIV, HCV and/or HBV
    positive, new testing need not be performed.

-   Assure that the exposed employee is provided with the source
    individual\'s test results and with information about applicable
    disclosure laws and regulations concerning the identity and
    infectious status of the source individual (e.g., laws protecting
    confidentiality).

-   After obtaining consent, collect exposed employee\'s blood as soon
    as feasible after exposure incident, and test blood for HBV, HCV,
    and HIV serological status

-   If the employee does not give consent for HIV serological testing
    during collection of blood for baseline testing, preserve the
    baseline blood sample for at least 90 days; if the exposed employee
    elects to have the baseline sample tested during this waiting
    period, perform testing as soon as feasible.

**ADMINISTRATION OF POST-EXPOSURE EVALUATION AND FOLLOW-UP**

The medical evaluation for a suspected exposure to blood or other
potentially infectious material should be done as soon as possible after
the exposure. The effectiveness of certain vaccines or other medication,
which might prevent any illness resulting from these exposures, is
greatest if given promptly after the exposure. (For post-exposure
prophylaxis for HIV, see CDC guidance at:
<http://www.cdc.gov/mmwr/PDF/rr/rr5409.pdf>.)

The following information must be provided by the post MED contact to
the healthcare professional evaluating an employee after an exposure
incident.

-   A copy of the OSHA Bloodborne Standard:
    <http://osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051>.

-   A description of the employee\'s job duties relevant to the exposure
    incident

-   Route(s) of exposure

-   Circumstances of exposure

-   If possible, results of the source individual\'s blood test

-   Relevant employee medical records, including vaccination status

The employee shall receive a copy of the evaluating healthcare
professional's written opinion within 15 days of the completion of the
medical evaluation, and a copy is to be sent to the Chief of
Occupational Health, MED/DASHO/OH. See Appendix E, **"**Healthcare
Professional's Post-Exposure Written Opinion.**"**

**PROCEDURES FOR EVALUATING THE CIRCUMSTANCES SURROUNDING AN EXPOSURE
INCIDENT**

The supervisor, with the assistance of the POSHO if necessary, will
review the circumstances of all exposure incidents to determine:

-   Engineering controls in use at the time

-   Work practices followed

-   A description of the device being used (including type and brand)

-   Protective equipment or clothing that was used at the time of the
    exposure incident (gloves, eye shields, etc.)

-   Location of the incident (lab, exam room, phlebotomy station, etc.)

-   Procedure being performed when the incident occurred

-   Employee\'s training

This information should be documented on the DS-1663. MED/DASHO/OH will
record all percutaneous injuries from contaminated sharps in a Sharps
Injury Log.\
\
If revisions to this plan are necessary MED/DASHO/IH will ensure that
appropriate changes are made.

**EMPLOYEE TRAINING**

All employees who have occupational exposure to bloodborne pathogens
receive initial and annual training conducted by MED/DASHO/OH, RMO, RMT,
or via online training.

All employees who have occupational exposure to bloodborne pathogens
receive training on the epidemiology, symptoms, and transmission of
bloodborne pathogen diseases. In addition, the training program covers,
at a minimum, the following elements:

-   A copy and explanation of the OSHA bloodborne pathogen standard

-   An explanation of our exposure control plan and how to obtain a copy

-   An explanation of methods to recognize tasks and other activities
    that may involve exposure to blood and other potentially infectious
    material, including what constitutes an exposure incident

-   An explanation of the use and limitations of engineering controls,
    work practices, and PPE

-   An explanation of the types, uses, location, removal, handling,
    decontamination, and disposal of PPE

-   An explanation of the basis for PPE selection

-   Information on the hepatitis B vaccine, including information on its
    efficacy, safety, method of administration, the benefits of being
    vaccinated, and that the vaccine will be offered free of charge

-   Information on the appropriate actions to take and persons to
    contact in an emergency involving blood or other potentially
    infectious material

-   An explanation of the procedure to follow if an exposure incident
    occurs, including the method of reporting the incident and the
    medical follow-up that will be made available

-   Information on the post-exposure evaluation and follow-up that the
    employer is required to provide for the employee following an
    exposure incident

-   An explanation of the signs and labels and/or color coding required
    by the standard and used at this facility

-   An opportunity for interactive questions and answers with the person
    conducting the training session.

Training materials for BBP are available in a Power Point Presentation
available on the MED web site.

**RECORDKEEPING**

**Training Records**

Training records are completed for each employee upon completion of
training. These documents will be kept for at least three years by the
Health Unit or department.\
\
The training records include:

-   The dates of the training sessions

-   The contents or a summary of the training sessions

-   The names and qualifications of persons conducting the training

-   The names and job titles of all persons attending the training
    sessions

Employee training records will be provided upon request to the employee
or the employee\'s authorized representative within 15 working days.
MED/FSHP will keep a record of dates of training and will track annual
training due for all affected healthcare workers.

**Medical Records**\
Medical records are maintained for each employee with occupational
exposure in accordance with 29 *CFR* 1910.1020, \"Access to Employee
Exposure and Medical Records.\"\
\
Medical Informatics (MED/EX/MI) is responsible for maintenance of
required medical records that are kept on e-Med. These records are
confidential and are kept for at least the duration of employment plus
30 years.\
\
Employee medical records are provided upon request of the employee or to
anyone having written consent of the employee within 15 working days.
Such requests should be sent to MED/ES/MI.\
\
**OSHA Recordkeeping**\
An exposure incident is evaluated to determine if the case meets OSHA\'s
Recordkeeping Requirements (29 CFR 1904). This determination and the
recording activities are done by SHEM for overseas incidents and DESD
for domestic incidents. SHEM and DESD will notify MED/DASHO/OH of any
sharps injuries.\
\
**Sharps Injury Log**\
In addition to the 1904 Recordkeeping Requirements, all percutaneous
injuries from contaminated sharps are also recorded in a Sharps Injury
Log. All incidences must include at least:

-   Date of the injury

-   Type and brand of the device involved (syringe, suture needle)

-   Department or work area where the incident occurred

-   Explanation of how the incident occurred.

-   For privacy, the name of injured individual is not to be listed

This log is reviewed as part of the annual program evaluation and
maintained for at least five years following the end of the calendar
year covered. If a copy is requested by anyone, it must have any
personal identifiers removed from the report. The sharps injury log will
be maintained by MED/DASHO/OH.

**Appendix A**

**Definitions**

***Blood*** means human blood, human blood components, and products made
from human blood.\
\
***Bloodborne Pathogens*** means pathogenic microorganisms that are
present in human blood and can cause disease in humans. These pathogens
include, but are not limited to, hepatitis B virus (HBV) and human
immunodeficiency virus (HIV).\
\
***Clinical Laboratory*** means a workplace where diagnostic or other
screening procedures are performed on blood or other potentially
infectious materials.\
\
***Contaminated*** means the presence or the reasonably anticipated
presence of blood or other potentially infectious materials on an item
or surface.\
\
***Contaminated Laundry*** means laundry which has been soiled with
blood or other potentially infectious materials or may contain sharps.\
\
***Contaminated Sharps*** means any contaminated object that can
penetrate the skin including, but not limited to, needles, scalpels,
broken glass, broken capillary tubes, and exposed ends of dental wires.\
\
***Decontamination*** means the use of physical or chemical means to
remove, inactivate, or destroy bloodborne pathogens on a surface or item
to the point where they are no longer capable of transmitting infectious
particles and the surface or item is rendered safe for handling, use, or
disposal.\
\
***Director*** means the Director of the National Institute for
Occupational Safety and Health, U.S. Department of Health and Human
Services, or designated representative.\
\
***Engineering Controls*** means controls (e.g., sharps disposal
containers, self-sheathing needles, safer medical devices, such as
sharps with engineered sharps injury protections and needleless systems)
that isolate or remove the bloodborne pathogens hazard from the
workplace.\
\
***Exposure Incident*** means a specific eye, mouth, other mucous
membrane, non-intact skin, or parenteral contact with blood or other
potentially infectious materials that results from the performance of an
employee\'s duties.\
\
***Handwashing Facilities*** means a facility providing an adequate
supply of running potable water, soap and single use towels or hot air
drying machines.\
\
***Licensed Healthcare Professional*** is a person whose legally
permitted scope of practice allows him or her to independently perform
the activities required by paragraph (f) Hepatitis B Vaccination and
Post-exposure Evaluation and Follow-up.\
\
***HBV*** means hepatitis B virus.

*HCV* means hepatitis C virus.\
\
***HIV*** means human immunodeficiency virus.\
\
***Needleless systems*** means a device that does not use needles for:\
\
(1) The collection of bodily fluids or withdrawal of body fluids after
initial venous or arterial access is established; (2) The administration
of medication or fluids; or (3) Any other procedure involving the
potential for occupational exposure to bloodborne pathogens due to
percutaneous injuries from contaminated sharps.\
\
***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 an
employee\'s duties.\
\
***Other Potentially Infectious Materials*** means (1) 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; (2)
Any unfixed tissue or organ (other than intact skin) from a human
(living or dead); and (3) 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.\
\
***Parenteral*** means piercing mucous membranes or the skin barrier
through such events as needlesticks, human bites, cuts, and abrasions.\
\
***Personal Protective Equipment*** is specialized clothing or equipment
worn by an employee for protection against a hazard. General work
clothes (e.g., uniforms, pants, shirts or blouses) not intended to
function as protection against a hazard are not considered to be
personal protective equipment.\
\
***Production Facility*** means a facility engaged in industrial-scale,
large-volume or high concentration production of HIV or HBV.\
\
***Regulated Waste*** means liquid or semi-liquid blood or other
potentially infectious materials; contaminated items that would release
blood or other potentially infectious materials in a liquid or
semi-liquid state if compressed; items that are caked with dried blood
or other potentially infectious materials and are capable of releasing
these materials during handling; contaminated sharps; and pathological
and microbiological wastes containing blood or other potentially
infectious materials.\
\
***Research Laboratory*** means a laboratory producing or using
research-laboratory-scale amounts of HIV or HBV. Research laboratories
may produce high concentrations of HIV or HBV but not in the volume
found in production facilities.\
\
***Sharps with engineered sharps injury protections*** means a
non-needle sharp or a needle device used for withdrawing body fluids,
accessing a vein or artery, or administering medications or other
fluids, with a built-in safety feature or mechanism that effectively
reduces the risk of an exposure incident.\
\
***Source Individual*** means any individual, living or dead, whose
blood or other potentially infectious materials may be a source of
occupational exposure to the employee. Examples include, but are not
limited to, hospital and clinic patients; clients in institutions for
the developmentally disabled; trauma victims; clients of drug and
alcohol treatment facilities; residents of hospices and nursing homes;
human remains; and individuals who donate or sell blood or blood
components.\
\
***Sterilize*** means the use of a physical or chemical procedure to
destroy all microbial life including highly resistant bacterial
endospores.\
\
***Universal Precautions*** is an approach to infection control.
According to the concept of Universal Precautions, all human blood and
certain human body fluids are treated as if known to be infectious for
HIV, HBV, HCV, and other blood borne pathogens.\
\
***Work Practice Controls*** means controls that reduce the likelihood
of exposure by altering the manner in which a task is performed (e.g.,
prohibiting recapping of needles by a two-handed technique).

**Appendix B**

Medical Waste Policy

1.  The Office of Medical Services has established a medical waste
    policy providing for the control of medical waste from its point of
    origin to its final disposal. The policy is intended to protect
    patients, health care workers, visitors, and the environment in
    accordance with applicable federal laws and regulations. The
    healthcare worker, laboratory employee, etc., who produce medical
    waste will hereinafter be denoted by the word generator.

2.  Medical waste is defined by the Environmental Protection Agency in
    regulations published in the Federal Register (40 CFR parts 22 and
    259). Federal facilities, research institutions, and companies
    producing vaccines are covered by the regulations. Medical waste
    affected by the act include:

-   Cultures and stocks of infectious agents including Petri dishes and
    laboratory equipment.

-   Human pathologic wastes, including body fluids, exudates, and
    excretions.

-   Blood and blood products including blood soiled material. Used blood
    donor bags or bottles and tubing are included in this category.

-   Contaminated needles, syringes, pipettes, scalpel blades, slides,
    cover slips, and test tubes - hereinafter referred to as sharps.

-   Contaminated animal carcasses, parts, and bedding from research
    facilities.

-   Soiled linen, excreta and medical waste from patients who have been
    placed in isolation.

-   Unused discarded needles, syringes, suture needles, and scalpel
    blades.

Handling, processing and disposal of medical waste:

1.  The generator shall identify infectious waste and separate it,
    preferably at the point of origin, from general trash. Mixtures of
    medical waste and general trash are considered to be medical waste.

2.  The generator shall use clearly labeled portable devices to store,
    transport, and dispose of medical waste thereby reducing or
    eliminating potential for causing disease. Containers should be
    located as close as practical to the generation area and should be
    leak-proof, puncture resistant, and autoclavable. M/MED recommends
    thick red tear-resistant plastic bags for collecting because the
    color red denotes material to be handled as infectious.

3.  The generator shall perform appropriate
    decontamination/sterilization procedures to reduce or eliminate
    disease transmission. There are several methods of assuring that
    medical waste is not infectious. Incineration is an ideal method but
    incinerators are costly and hence are not available at small medical
    sites. M/MED recommends autoclaving as the decontamination/
    sterilization procedure of choice for small medical sites overseas.
    However, treatment by chemical disinfection with a five percent
    solution of sodium hypochlorite (household bleach) is an acceptable
    alternative.

> 15 minutes of soaking in a solution of 600 ppm is sufficient. A 600
> ppm solution is made with three tablespoons of five percent household
> bleach (Clorox) in one gallon of water. The solution should be made up
> immediately prior to use. After decontamination/sterilization, the
> material, with the exception of sharps, may be handled as general
> trash. It is prudent to determine the final destination of trash from
> medical units to ensure disposal in a land fill and out of the public
> domain.

4.  Sharps should be handled with extraordinary care. Needles should not
    be removed, recapped, bent, snipped, or otherwise manipulated by
    hand but should be promptly deposited in a puncture resistant and
    clearly labeled and leak-proof container. Following
    decontamination/sterilization, sharps and syringes shall not be
    handled as general trash. Unused sharps (needles, scalpel blades,
    etc.) need not be decontaminated/sterilized prior to disposal and
    are also not handled as general trash.

5.  If storage of medical waste prior to transfer is necessary, the
    generator shall take steps to prevent waste from coming into contact
    with workers or the public. The storage area should be away from the
    patient areas in a lockable cabinet or closet. The cabinet or closet
    should be prominently labeled with a "infectious waste" sign.

6.  At overseas sites the generator will, after autoclaving or chemical
    disinfection, ensure the transport of sharps to an appropriate
    disposal facility. The ideal disposal is at a landfill, e.g. burial.
    M/MED recognizes that generators at overseas sites may encounter
    major difficulties ensuring burial of sharps in a sanitary landfill.
    If no acceptable means of disposal is at hand the generator may
    elect to use Safe-Pak medical waste disposal containers which are
    commercially available from, for example, Henry Schein, Inc., 5
    Harbor Park Drive, Port Washington, NY, 11058. The cost of the
    container includes disposal service and the containers comply with
    federal and postal regulations. The generator will maintain records
    to track the ultimate disposal.

7.  Emergencies, including spills, ruptures of plastic bags, or other
    containers, and equipment failure call for immediate
    decontamination. Waste handlers with exposed contaminated skin
    surfaces should wash immediately and thoroughly with soap and water.
    Commercially available chemical germicides or household bleach
    (sodium hypochlorite) may be used on the surfaces to be cleaned and
    disinfected.

8.  Blood and other bodily fluids may be flushed directly into a
    sanitary sewer.

All employees who generate or handle infectious waste material,
including cleaners and trash handlers, shall receive infectious waste
management training which shall include:

-   A complete explanation of the medical waste policy

-   Assignment of responsibilities for implementation of the policy

-   Regular refresher courses

-   Instruction in the use of gloves, eye protectors, masks and other
    barrier methods.

Appropriate protective devices, including laboratory coats and uniforms
will be provided by the health facility.

A log must be maintained that contains information on every shipment of
medical waste. The log must be maintained on-site for three (3) years
from the date of the most recent entry and must provide the following
information:

-   Date

-   Signature of generator

-   Transporter's name and address if shipped outside the health
    facility

-   Quantity and category of waste

-   Destination

-   If a Safe-Pak is mailed via U.S. Postal Service, the package will be
    sent by registered mail and return receipt requested. Only if U.S.
    Postal Service is not available the shipment may be sent by
    registered pouch to M/MED/LAB for outward mailing.

Generators may contact the Medical Director for any questions related to
this policy.

Addendum: the principles of M/MED's medical waste policy are appropriate
to the disposal of outdated medications. A health care worker shall
supervise the destruction of all outdated medication to ensure it does
not become hazardous material.

**Appendix C**

**Employee Exposure Determination Guide**

Unit:

Address:

Prepared by:

Date:

Date reviewed for update:

a.  List job titles or classifications where employees have routine
    occupational exposure:

b.  List job titles or classifications where employees may occasionally
    have occupational exposure:

c.  List those tasks and procedures performed wherein occupational
    exposure can occur:

d.  Describe your handling and disposal techniques for contaminated
    needles and sharps:

e.  Describe your handling of contaminated reusable instruments,
    including sharps:

f.  Describe your handling and disposal of regulated waste, other than
    sharps:

g.  Describe your handling of contaminated laundry:

h.  Describe your cleaning procedures for spills of blood or other
    potentially infectious materials:

i.  List other procedures performed where there is occupational exposure
    to blood and other potentially infectious materials and indicate the
    personal protective equipment required for each:

NOTE: Part-time, temporary, contract and per diem employees are covered
by the bloodborne pathogens standard. These employees are to be included
in the determination.

**Appendix D**

**Hepatitis B Vaccine Declination Form (Mandatory)**

I understand that, due to my occupational exposure to blood or other
potentially infectious materials, I may be at risk of acquiring
hepatitis B virus (HBV) infection. I have been given the opportunity to
be vaccinated with hepatitis B vaccine, at no charge to myself. However,
I decline hepatitis B vaccination at this time. I understand that by
declining this vaccine, I continue to be at risk of acquiring hepatitis
B, a serious disease. If in the future I continue to have occupational
exposure to blood or other potentially infectious materials and I want
to be vaccinated with hepatitis B vaccine, I can receive the vaccination
series at no charge to me.

­­­­­­­­­­­­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Print Name Signature

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date

**Appendix E**

#### Healthcare Professional's Post-Exposure Written Opinion

Exposed Employee's Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Facility:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

As required by the OSHA Bloodborne Pathogen Standard:

In my opinion, hepatitis B vaccination (is, is not) indicated for the
above named employee. As of this date, the above named employee (has,
has not) received such vaccination.

The above named employee has been informed of the results of the medical
evaluation.

Yes No

The above named employee has been told about any medical conditions
resulting from exposure to blood or other potentially infectious
materials, which require further evaluation or treatment. Yes No

All other findings or diagnosis shall remain confidential and shall not
be included in this written report.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Healthcare Professional

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Printed or Typed Name of Healthcare Professional

\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date

Distribution:

One copy to the exposed employee

Overseas: one copy to the Post Occupational Safety and Health Officer
(POSHO) and one copy to the Chief of Occupational Health, MED/DASHO/OH

Washington, DC: one copy to the Chief of Occupational Health,
MED/DASHO/OH

**Appendix F**

MEDICAL INCIDENT

### *This form is to be included with the required reporting of medical incidents/surveillance together with CDC Appendix A-7, original retained at HU, and copy forwarded to MED/DASHO 202-663-3666, fax 202-663-3673.*

### 

### **Part I - Report Form: Potential HIV or Blood Borne Pathogen Exposure**

1\. Name of Employee or Eligible Family Member:

#  Last First MI 

2\. Date of birth:

3\. Sex: Male / Female (circle) If female, is individual pregnant?

4\. Telephone number: Work Home

5\. Date time of exposure: day /month /year /hour (am/pm)

6\. Location where exposure occurred:
City\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Country

7\. Type of exposure (check and describe):

\[ \] Percutaneous (needle/sharp object that was in contact with blood
or body fluids)):

\[ \] Mucous membrane:

\[ \] Skin -- intact:

\[ \] Skin -- broken:

\[ \] Sexual (in detail):

\[ \] Bite

\[ \] Additional information/ occupation:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8\. Source material (check and/or circle all that apply):

\[ \] Blood

\[ \] Fluid containing visible blood, other potentially infectious fluid
or tissue

\[ \] Other body fluid (e.g., urine, saliva, semen, vaginal fluid)

> Explain:

9\. First Aid: Washing; rinsing; antiseptic:

10\. Viral status of source/exposure (check one):

> A. HIV -

\[ \] HIV-infected, documented by:
(test)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(date)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is the source person on anti-retroviral drugs? If yes, give details

\[ \] HIV-uninfected, documented by:
(test)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
(date)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \[ \] HIV-status unknown

> B. Hepatitis B surface antigen: Reactive/Non-reactive. Date
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\
> If positive. Hepatitis B Antigen: reactive or non-reactive-Antibody
> Status: reactive or non-reactive

#  C. HCV status: Reactive/Non-reactive. Date 

> 11\. Medical Status of exposed person:\
> A. HIV. Previous HIV testing? Date and Result

# **Part I - Report Form: Potential HIV or Blood Borne Pathogen Exposure (continued)**

#  B. Hepatitis B. History of Hepatitis B vaccine: Yes No 

  ----------------- --------------- ------------------ ------------------
  Vaccine                                              
  brand/dose                                           

  Date of Dose                                         
  ----------------- --------------- ------------------ ------------------

> Results of post hepatitis B vaccine anti-HBs\
> Health care workers 1-6 months after 3^rd^ dose: \>10 mIU/ml or \<10
> mIU/ml.\
> Date of test: Unknown

Pre-exposure antibody to hepatitis B core antibody (anti-HBc):

Reactive / Non-reactive / Unknown. Date:

C. Hepatitis C. Results of Pre-exposure anti-HCV testing:\
Non-reactive or Reactive on date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_

#  D. Tetanus. Date of last tetanus containing immunization: 

12\. Infectious Disease Specialist Consulted (Name and phone #):

[Attach written report]{.underline}

13\. Disposition:

\[ \] Counseling. Advised to use precautions to prevent secondary
transmission during follow-up period and informed about possible drug
toxicities and drug interactions.

> \[ \] Medical evacuation to: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> Contact person: (location)
>
> \[ \] Treatment at post:

14\. Post-exposure prophylaxis (check one):

\[ \] Recommended

\[ \] Not Recommended

15\. HIV PEP begun: Date: day /month /year /time (am/pm)

  -------------------------- ------------- -------------- ----------------
  Medication                 Dose          Frequency      Duration

                                                          

                                                          

                                                          
  -------------------------- ------------- -------------- ----------------

Z*idovudine (ZDV) and lamivudine (3TC);*

*A protease inhibitor or other class may be added following high-risk
exposures (see below)(e.g.,, Kaletra)*

16\. Hepatitis B Post-exposure prophylaxis

> A. Hepatitis B Immune Globulin: Yes/No (Rec. if source is positive for
> HBsAg and exposed is susceptible)

B. Hepatitis B vaccine offered: Yes/No (Rec. if exposed is susceptible
or source is HBsAg reactive or unknown)

#  Dates of doses: 

Tetanus toxoid offered: Yes / Not needed. Date given

Patient and/or guardian's signature Date

Healthcare Professional's signature Date

#### Part II - Follow-up Four (4) Weeks After Exposure

Medications: Doses of medication 1 completed: Days completed

Doses of medication 2 completed: Days completed

Doses of medication 3 completed: Days completed

Results of post exposure evaluation:

# Anti-HIV Result: Non-reactive or Reactive Date of Test \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Anti-HCV Result: Non-reactive or Reactive Date of Test \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

# HBsAg Result: Non\--reactive or Reactive Date of Test\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Anti-HBc Result: Non-reactive or Reactive Date of Test
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# 

# Part III: Six Months after Exposure

# Anti-HIV Result: Non-reactive or Reactive Date of Test \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Anti-HCV Result: Non-reactive or Reactive Date of Test \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

# HBsAg Result: Non\--reactive or Reactive Date of Test 

Anti-HBc Result: Non-reactive or Reactive Date of Test
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**References**

Updated U.S. Public Health Service Guidelines for the Management of
Occupational Exposures to HIV and Recommendations for Postexposure
Prophylaxis (MMWR, September 30, 2005):

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm>

Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug
Use, or Other Non-occupational Exposure to HIV in the United States
(MMWR January 21, 2005):

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm>

CDC STD Treatment Guidelines 2006:

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm>

National Clinicians' Consultation Center:

<http://www.ucsf.edu/hivcntr/Clinical_Resources/PEPGuidelines.html>

**Medication Log for Post Exposure Prophylaxis**

**(**Record medication, dose in mg, and number of tablets taken daily)

# NAME: 

  ------- ---------- ------------------- ------------------- -------------------------
  **Day   **Date**   **Medication/mg/#   **Medication/mg/#   **Medication/mg/#tabs**
  No.**              tabs**              tabs**              

  1                                                          

  2                                                          

  3                                                          

  4                                                          

  5                                                          

  6                                                          

  7                                                          

  8                                                          

  9                                                          

  10                                                         

  11                                                         

  12                                                         

  13                                                         

  14                                                         

  15                                                         

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  17                                                         

  18                                                         

  19                                                         

  20                                                         

  21                                                         

  22                                                         

  23                                                         

  24                                                         

  25                                                         

  26                                                         

  27                                                         

  28                                                         

  29                                                         

  30                                                         
  ------- ---------- ------------------- ------------------- -------------------------