HomeMy WebLinkAboutAgreement A-15-180 with SJVC.pdfAGREEMENT N0.15-180
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this /9 -lh , 2015,
3 by and between the COUNTY OF FRESNO, a political subdivision ofthe State of California,
4 hereinafter referred to as "COUNTY", and SAN JOAQUIN VALLEY COLLEGE a For-Profit
5 Corporation, whose address is 3828 W. Caldwell Avenue, Visalia, California 93277, hereinafter
6 referred to as "COLLEGE".
7 WITNESSETH:
8 WHEREAS, COLLEGE, has approved various educational training programs that require
9 facilities to provide clinical and field experience for required learning experiences for its students; and
10 WHEREAS, COUNTY, through its Department of Behavioral Health (DBH) and Department
11 ofPublic Health (DPH), maintains and operates facilities suitable for furnishing such clinical and field
12 experience; and
13 WHEREAS, it is to the mutual benefit of the parties hereto that personnel an:d students of
14 COLLEGE use such facilities of COUNTY for their clinical and field experience; and
15 WHEREAS, those students participating in the following COLLEGE departments/programs are
16 subject to this Agreement;
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18
19
20
21
1.
2.
3.
4.
5.
Medical Programs
Nursing Programs
Social Science Program
Psychology Programs
Drug and Alcohol Counseling Programs
22 NOW, THEREFORE, in consideration oftheir mutual covenants and conditions, the parties
2 3 hereto agree as follows:
24 1. RESPONSIBILITIES OF COLLEGE
25 A. COLLEGE agrees that each participating student and/or instructor from
2 6 COLLEGE shall be in compliance with COUNTY's health clearance requirements. Prior to the first
27 clinical rotation of each student and/or instructor at COUNTY's facilities, COLLEGE must provide
28 COUNTY documentary proofthat each student and/or instructor assigned to COUNTY meets
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COUNTY'S health clearance requirement,including,but not limited to:
1) Hepatitis B Vaccination Series OR Hepatitis B Vaccine Declination Form
- Sincethe work may lead to a reasonable anticipated skin, eye, mucous membrane, or potential
contact with blood or other potentially infectious materials,each student and/or instructor must have
receiveda Hepatitis B vaccination series prior to commencing placement at COUNTY. In lieuof
studentand/orinstructorcertifyingto COUNTYthat the studenthas been vaccinatedfor Hepatitis B,
COUNTYwill accept from each student and/or instructor a form declining the Hepatitis B
vaccination. The declination form shall comply with the requirements of 29 Code of Federal
Regulations,Section 1910.1030,as set forth in ExhibitA, which is attached heretoand incorporated
herein. Students and/or instructors may use COUNTY'S "Hepatitis B Vaccine Declination Form",
attachedhereto as Exhibit B and incorporated herein, to meet the above requirements; and
2)Proof of a negative skin test for tuberculosis (TB) within the past twelve
(12)months,an initial assessment and yearly assessment for signs and symptoms of diseasewill be
required; and
3)Proof of vaccination for Measles, Mumps, and Rubella (MMR) or
serological evidence of immunity to rubella or rubeola;and
4)Proof of fulfillment of Occupational Safety and Health Administration
(OSHA)Blood-BornePathogen Standards(mandatedtrainingand post-exposure follow-up);and
5)Proof of any other health clearance requirements as may be mandated
during thetermofthisAgreementby COUNTY dueto licensing regulationsand/or requirements.
B.COUNTY and COLLEGE mutually recognize that the health clearance
requirements identifiedabove may be differentand/or may change, as determined by COUNTY,
dependingupon classification of student and/or instructor and the type of work performed in addition
to potential patient exposure.
C. COLLEGE recognizes that the clinical and field experience education programs
conducted pursuantto the terms and conditions of this Agreementare educational programsof
COLLEGE and not of COUNTY,and that studentsparticipatingin COLLEGE'Sprogramsshallat all
times be under the exclusive jurisdiction of COLLEGE.
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D. COLLEGE shall designatestudentsenrolledin the various educationaltraining
programs of COLLEGE to be assigned for clinical and field experience at COUNTYs facilities, in
such numbers to be mutually agreed upon by both COUNTY and COLLEGE.
E.COLLEGE shall establish a rotational plan for the learning experience available
at COUNTY'S facilities and shall schedule the students in conformity with the calendar of
COLLEGE'S academic year and with the curriculum of the educational programs of COLLEGE;
provided,however, that the specific COUNTY patient care areas to be utilized by COLLEGE shall be
selected subsequently by mutual agreement between COUNTY'S DBH and/or DPH Director(s), or
their designee(s),and COLLEGE'S chairperson(s) or duly authorized representative(s)of the various
departments/programs listed in the "Witnesseth"section of this Agreement hereinabove.
F.COLLEGE shall supervise all instruction of the clinical and field experience
given at COUNTY facilities to assigned students and shall provide the necessary instructors for
educational training programs provided for under this Agreement.
G.COLLEGE shall keep all attendance and academic records of students
participating in the clinical and field experience programs provided under this Agreement.
H.COLLEGE shall certify to COUNTY at the time each student first reports to
COUNTY'S facilities to participate in the clinical and field experience education program, that the
student is enrolled with COLLEGE'S available health plan for students.
I.COLLEGE shall ensure students act professionally and appropriately while at
COUNTY facilities.
J.COLLEGE shall require every student to conform to all COUNTY policies,
procedures, regulations, and all requirements and restrictions specified jointly by representatives of
COLLEGEand COUNTY. Policies shall be provided to the student prior to his or her placement
within a Clinical and Field Experience position within the COUNTY.
K.COLLEGE shall require its instructors to notify COUNTY'S DBH and/or DPH
Director(s),or designee (s), as appropriate in advance of student placement regarding:
1) Locations, dates, times and the number of hours or changes thereof,
regarding student availability for clinical or field assignment; and
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2) Any change in the placement of students in clinical and field
assignments.
L.COLLEGE shall,in consultation and coordination with COUNTY'S DBH and/or
DPH Director(s), or designee(s), arrange for periodic conferences between appropriate representatives
of COLLEGE and COUNTY to evaluate the clinical and field experience programs provided under
this Agreement. Periodic conferences shall take place as often as deemed appropriate by either party.
M.COLLEGE shall provide and be responsible for the use and control of its
educational supplies, materials and equipment used for instruction during the clinical and field
experience programs.
N.COLLEGE shall distribute to each student a statement which explains the
hazards of drug abuse in their profession.
O.COLLEGE shall provide for an introductory orientation of students assigned to
COUNTY facilities, which shall provide an overview of the clinical and field assignment(s) and the
terms and conditions of student placement at COUNTY facilities.
P.COLLEGE agrees that special reports,projects,thesis,and/or publications based
upon studiesand research arising out of the cooperative education experience permitted by this
Agreement,shall be reviewed and approved prior to release through the committee responsiblefor
planning the course and then by COUNTY'S DBH and/or DPH Director(s),or designee(s), as
appropriate, for approval by means of such procedures as COUNTY shall designate. Approval of
reports by COLLEGE'S planning committee and COUNTY'S DBH and /or DPH shall not be
unreasonably withheld.
Q.COLLEGE agrees to complete an evaluation of each student at least once during
a specific program period.
R.COLLEGE shall allow COUNTY program managers and other designated
personnel to attend meetings of COLLEGE'S faculty, or any committee thereof,to coordinate the
clinicaland field experience programs provided under this Agreement and to designate lines of
authority and communicationfor coordinationof relations between COUNTY personneland
COLLEGE instructors.
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S. COLLEGE'Semployees,agentsand students shall abide by Stateof California
law relating to confidentiality of medical records,further describedin Section 14ofthis Agreement,
andany person knowingly and intentionally violating the provisions of California lawmaybe guilty of
a misdemeanor.
T.COLLEGE'S employees,agents and students shall be issued COUNTY
identification badgeswhich must be worn onlyat COUNTYfacilities while participatinginthe
clinicaland fieldexperienceprograms,pursuantto the terms and conditions of this Agreement.
U. COLLEGE will ensure each participating student referred for program
participationhas adequate transportation and auto insurance as participating students will not be
permittedto operate COUNTY vehicles to perform activities related to this Agreement.
2.RESPONSIBILITES OF COUNTY
A. COUNTYshall permiteach studentwho is designated by COLLEGE,pursuant
to Section l.D.ofthis Agreement,to receiveclinicalandfield experience at appropriate COUNTY
facilities at an agreed (between COUNTY and COLLEGE) number of hours. COUNTY shall furnish
and permit students and/or instructors free access to appropriate COUNTY facilities for such clinical
and field experience, subject to the terms and conditions of this Agreement.
B.COUNTY shall furnish the appropriate facilities,on a rotational basis, in such a
manner that there will be no conflict in the use thereof between COLLEGE'S students and those from
other educational institutions,if any.
C.COUNTY shall, subject to budgetary and operational concerns, maintain clinical
and field facilities used for the learning experience in a manner that shall at all times conform to the
requirements of COLLEGE'S departments/programs listed in the "Witnesseth"section of this
Agreement hereinabove.
D. COUNTY shall provide staff adequate in number and quality to provide safe and
continuoushealth care to patients involved in clinical and field experience programs.
E.COUNTY shall provide to students and instructors taking part in the clinical and
field experience (subject to space limitations) the following facilities:
1) A conference type room or office space suitably furnished for
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COLLEGE'S instructors and faculty to conduct clinical and/or field classes;
2) A storage area for instructional materials and supplies;
3)Shelf space for books and other space for use by COLLEGE'S students
and instructors;and
4)Restroom facilities and appropriate space for changing and storage of
uniforms.
F.COUNTY shall provide emergency health care (on a fee-for-service basis) for
any student and/or instructor who become sick or injured by conditions arising out of or in the course
of any student's and/or instructor's participation in the clinical and field experience at COUNTY
facilities. The recipient of emergency health care shall be responsible for the payment of all
emergency health care services provided.
G.COUNTY shall permit and encourage members of its resident staff and/or
attending medical staff to participate in the instructional phase of COLLEGE'S clinical and field
experience programs.
H.COUNTY shall permit its various program directors and other designated
personnel to attend meetings of COLLEGE'S faculty,or any committee thereof,to coordinate the
clinical and field experience programs provided for under this Agreement and to designate lines of
authority and communication for coordination of relations between COLLEGE instructors and
COUNTY personnel.
I.COUNTY shall provide an introductory orientation for COLLEGE instructors
and faculty staff which provides an overview of COUNTY'S facilities,field and experience programs,
and the terms and conditions of student placement at COUNTY'S facilities.
J.COUNTY shall notify COLLEGE'S instructors,in advance,of any change in its
DBH and/or DPH Director(s),or designee(s)appointments.
K.COUNTY shall,within the limits of its resources,provide whatever equipment,
supplies and assistance necessary for the care of COUNTY patients in the course of COLLEGE'S
students learning experience and consistent with COUNTY'S plan of care.
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L.COUNTY shall reserve the absolute right to review,authorize,and at its sole
discretion,deny access or admission by any student,instructor and/or COLLEGE
representative into COUNTY facilities.
M.COUNTY shall provide input into the evaluation conducted by COLLEGE,of
students'skills and progress.
N.COUNTY shall agree to allow access to existing dining room space for students'
breakand meal periods. COLLEGE'S students shall purchase food in the regular system or bring food
with them; no special arrangements for food will be made.
3.TERM
This Agreement shall become effective onthe 1st day ofJuly 2015 and shall terminate
on the 30th day of June 2018.
Effective July 1st,2018,this Agreement,subject to satisfactory outcomes performance,
shall be extended for two (2)additional twelve (12)month periods upon the same terms and
conditions herein set forth, unless written notice of non-renewal is given by COLLEGE or COUNTY
or COUNTY'S DBH Director,or designee,not later than sixty (60)days prior to the close of the
current Agreement term.
4.TERMINATION
A.Non-Allocation of funds - The terms of this Agreement,and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving COLLEGE thirty (30) days advance written notice.
B.Breach of Contract -COUNTY may immediately suspend or terminate this
Agreement in whole or in part,where in the determination of COUNTY there is:
1) A failure to comply with any term of this Agreement;
2) A substantially incorrect or incomplete report submitted to COUNTY;or
3)Improperly performed service.
C.Without Cause -Under circumstances other than those set forth above,this
Agreement may be terminated by COLLEGE or COUNTY or COUNTY'S DBH Director, or designee,
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upon the giving of six (6)months advance written notice of an intention to terminate.
5.COMPENSATION
The clinical and field learning experience programs conducted pursuant to the terms and
conditions of this Agreement shall be performed without the payment of any monetary consideration
by COLLEGE or COUNTY, one to the other, or by or to any student participating in said clinical
training programs.
6.INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by COLLEGE under this
Agreement, it is mutually understood and agreed that COLLEGE,including any and all of
COLLEGE'S students, instructors, faculty, officers, agents, and employees will at all times be acting
and performing as independent contractors, and shall act in an independent capacity and not as an
officer, agent, servant, employee,joint venturer, partner, or associate of the COUNTY. Furthermore,
COUNTY shall have no right to control or supervise or direct the manner or method by which
COLLEGE shall perform its work and function. However,COUNTY shall retain the right to
administer this Agreement so as to verify that COLLEGE is performing its obligations in accordance
with the terms and conditions thereof. COLLEGE and COUNTY shall comply with all applicable
provisions of law and the rules and regulations,if any,of governmental authorities having jurisdiction
over matters which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor,COLLEGE shall have absolutely no
right to employment rights and benefits available to COUNTY employees. COLLEGE shall be solely
liableand responsible for providing to, or on behalf of, its employees all legally-required employee
benefits. In addition,COLLEGE shall be solely responsible and save COUNTY harmless from all
mattersrelating to payment of COLLEGE'S employees, including compliance with Social Security,
withholding,and all other regulations governing such matters. It is acknowledged that duringthe term
of this Agreement,COLLEGE may be providing services to others unrelated to COUNTY or to this
Agreement.
7.MODIFICATION
Any matters of this Agreement may be modified from time to time by the written
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consent of all the parties without, in any way, affecting the remainder.
Notwithstanding the above, changes in addresses to which notices are to be sent may be
made by written approval of COUNTY'S DBH Director or designee and COLLEGE.
8.NON-ASSIGNMENT
No party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of COUNTY and COLLEGE.
9.HOLD-HARMLESS
COLLEGE agrees to indemnify,save, hold harmless,and at COUNTY'S request, defend
COUNTY, its officers, agents and employees from any and all costs and expenses, including attorney
fees and court costs,damages,liabilities,claims and losses occurring or resulting to COUNTY in
connection with the performance,or failure to perform,by COLLEGE,its officers,agents, students, or
employees under this Agreement,and from any and all costs and expenses, including attorney fees and
court costs, damages, liabilities, claims and losses occurring or resulting to any person, firm or
corporation who may be injured or damaged by the performance, or failure to perform,of COLLEGE,
its officers, agents,students or employees under this Agreement.
COLLEGE agrees to indemnify COUNTY for Federal and/or State of California audit
exceptions resulting from noncompliance herein on the part of COLLEGE.
COUNTY and COLLEGE shall give timely notice to the other of any claim, demand,
lien, or suit coming to its knowledge which in any way might affect the other party and each party
shall have the right to participate in the defense of the same to the extent of its interest.COUNTY and
COLLEGE recognize that the significant mutual benefits of this Agreement depend upon close
cooperation and good faith handling of matters subject to such indemnification provisions.
10.INSURANCE
Without limiting COUNTY'S right to obtain indemnification from COLLEGE or any
third parties,COLLEGE,at its sole expense,shall maintain in full force and effect the following
insurance policies throughout the term of this Agreement:
A.Commercial General Liability
Commercial General Liability Insurance with limits of not less than One Million
Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million
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Dollars ($2,000,000).This policy shall be issued on a per occurrencebasis.
COUNTY may require specific coverage including completed operations,
product liability, contractual liability, Explosion, Collapse, and Underground
(XCU), fire legal liability or any other liability insurance deemed necessary
because of the nature of the Agreement.
B.Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily injury of
not less than Two Hundred Fifty Thousand Dollars ($250,000) per person, Five
Hundred Thousand Dollars ($500,000) per accident and for property damages of
not less than Fifty Thousand Dollars ($50,000), or such coverage with a
combined single limit of Five Hundred Thousand Dollars ($500,000). Coverage
should include owned and non-owned vehicles used in connection with this
Agreement.
C. Real and Personal Property
COLLEGE shall maintain a policy of insurance for all risk personal property
coverage which shall be endorsed naming the County of Fresno as an additional
loss payee. The personal property coverage shall be in an amount that will cover
the total of the County purchased and owned property,at a minimum, as
discussed in Section Sixteen (16)of this Agreement.
D. All Risk Property Insurance
COLLEGE will provide property coverage for the full replacement value of the
County's Personal Property in the possession of COLLEGE and/or used in the
execution of this Agreement. COUNTY will be identified on an appropriate
certificate of insurance as the certificate holder and will be named as an
Additional Loss Payee on the Property Insurance Policy.
E.Professional Liability
If COLLEGE employs licensed professional staff (e.g. Ph.D., R.N., L.C.S.W.,
L.M.F.T.)in providing services,Professional Liability Insurance with limits of
not less than One Million Dollars ($1,000,000) per occurrence,Three Million
Dollars ($3,000,000) annual aggregate. COLLEGE agrees that it shall maintain,
at its sole expense, in full force and effect for a period of three (3) years
following the termination of this Agreement, one or more policies of professional
liability insurance with limits of coverage as specified herein.
F.Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
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California Labor Code. COLLEGE shall be responsible for Worker's
Compensation coverage for students who participate in the program.
G. Child Abuse/Molestation and Social Services Coverage
COLLEGE shall have either separate policies or umbrella policy with
endorsements covering Child Abuse/Molestation and Social Services Liability
coverage or have a specific endorsement on their General Commercial liability
policy covering Child Abuse/Molestation and Social Services Liability. The
policy limits for these policies shall be $1,000,000 per occurrence with
$2,000,000annual aggregate.The policies are to be on a per occurrence basis.
COLLEGE shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees,individually and collectively, as
additional insured, but only insofar as the operations under this Agreement are concerned. Such
coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance,maintained by the COUNTY, its officers, agents and employees shall be excess only and
not contributing with insurance provided under COLLEGE'Spolicies herein. This insurance shall not
be cancelledor changed without a minimum of thirty (30) days advance written notice givento
COUNTY.
Within thirty (30) days from the date COLLEGE signs this Agreement, COLLEGE
shall providecertificates of insurance and endorsements as stated above for all of the foregoing
policies, as required herein,to the County of Fresno,Department of Behavioral Health,3133 N.
Millbrook Avenue, Fresno,California 93703, Attention: Mental Health Contracts Section, stating that
such insurance coverages have been obtained and are in full force;that the County of Fresno, its
officers, agents and employees will not be responsible for any premiums on the policies; that such
Commercial General Liability insurance names the County of Fresno, its officers, agents and
employees,individually and collectively, as additional insured, but only insofar as the operations
underthis Agreementare concerned;that suchcoveragefor additional insured shall applyas primary
insuranceand any other insurance, or self-insurance, maintained by COUNTY, its officers, agentsand
employees, shall be excess only and not contributing with insurance provided under COLLEGE'S
policies herein;and that this insuranceshall not be cancelledor changed without a minimumofthirty
(30) days advance,written notice given to COUNTY.
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In the event COLLEGE fails to keep in effect at all times insurance coverage as herein
provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this
Agreement upon the occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of
California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc.rating
ofAFSC VIII or better.
11.LICENSES/CERTIFICATES
Throughout each term of this Agreement,COLLEGE and COLLEGE'S staff shall
maintainall necessary licenses, permits, approvals, certificates, waivers and exemptions necessaryfor
the provision of the services hereunder and required by the laws and regulations of the United States
of America, State of California, the County of Fresno, and any other applicable governmental
agencies. COLLEGE shall notify COUNTY immediately in writing of its inability to obtain or
maintain such licenses, permits, approvals, certificates, waivers and exemptions irrespectiveof the
pendency of any appeal related thereto. Additionally, COLLEGE and COLLEGE'S staff shall comply
with all applicable laws, rules or regulations, as may now exist or be hereafter changed.
12.MONITORING
COLLEGE agrees to extend to COUNTY'S staff,COUNTY'S DBH Director and the
CaliforniaDepartment of Health Care Services (DHCS), or their designees, the right to review and
monitor records,programs or procedures,at any time, in regard to clients,as well as the overall
operation of COLLEGE'S programs,in order to ensure compliance with the terms and conditions of
this Agreement.
!3-REFERENCES TO LAWS AND RULES
In the event any law, regulation, or policy referred to in this Agreement is amended
during the term thereof, the parties hereto agree to comply with the amended provision as of the
effective date of such amendment.
14.HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
A. The parties to this Agreement shall be in strict conformance with all applicable
Federal and State of California laws and regulations,including but not limited to Sections 5328,
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10850,and 14100.2 et seq.of the Welfare and Institutions Code, Sections 2.1 and 431.300 etseq.of
Title 42, Code of Federal Regulations (CFR),Section 56 et seq.of the California Civil Code, and the
Health Insurance Portability and Accountability Act (HIPAA),including but not limited to Section
1320 D etseq.of Title 42, United States Code (USC) and its implementing regulations,including, but
not limited to Title 45, CFR, Sections 142,160,162,and 164,The Health Information Technology for
Economic and Clinical Health Act (HITECH) regarding the confidentiality and security of patient
information, and the Genetic Information Nondiscrimination Act (GINA)of 2008 regarding the
confidentiality of genetic information.
Except as otherwise provided in this Agreement,COLLEGE,as a Business
Associate of COUNTY, may use or disclose Protected Health Information (PHI) to perform functions,
activities or services for or on behalf of COUNTY, as specified in this Agreement, provided that such
use or disclosure shall not violate the Health Insurance Portability and Accountability Act (HIPAA),
USC 1320d et seq.The uses and disclosures of PHI may not be more expansive than those applicable
to COUNTY, as the "Covered Entity"under the HIPAA Privacy Rule (45 CFR 164.500 et seq.),
except as authorized for management,administrative or legal responsibilities of the Business
Associate.
B.COLLEGE,including its subcontractors and employees,shall protect, from
unauthorized access, use, or disclosure of names and other identifying information,including genetic
information,concerning persons receiving services pursuant to this Agreement,except where
permitted in order to carry out data aggregation purposes for health care operations [45 CFR Sections
164.504 (e)(2)(i), 164.504 (3)(2)(ii)(A),and 164.504 (e)(4)(i)] This pertains to any and all persons
receiving services pursuant to a COUNTY funded program. This requirement applies to electronic
PHI.COLLEGE shall not use such identifying information or genetic information for any purpose
other than carrying out COLLEGE'S obligations under this Agreement.
C.COLLEGE,including its subcontractors and employees,shall not disclose any
such identifying information or genetic information to any person or entity,except as otherwise
specifically permitted by this Agreement,authorized by Subpart E of 45 CFR Part 164 or other law,
required by the Secretary,or authorized by the client/patient in writing. In using or disclosing PHI
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that is permitted by this Agreement or authorized by law,COLLEGE shall make reasonable efforts to
limitPHIto the minimum necessaryto accomplishintendedpurpose of use, disclosureor request.
D. For purposes of the above sections,identifying information shall include, but not
be limited to name, identifying number, symbol, or other identifying particular assigned to the
individual, such as finger or voice print, or photograph.
E. For purposes of the above sections, genetic information shall include genetic
tests of family members of an individual or individual, manifestation of disease or disorder of family
members of an individual, or any request for or receipt of, genetic services by individual or family
members. Family member means a dependent or any person who is first,second,third, or fourth
degree relative.
F.COLLEGE shall provide access, at the request of COUNTY,and in the time and
manner designated by COUNTY,to PHI in a designated record set (as defined in 45 CFR Section
164.501),to an individual or to COUNTY in order to meet the requirements of 45 CFR Section
164.524 regarding access by individuals to their PHI. With respect to individual requests, access shall
be provided within thirty (30) days from request. Access may be extended if COLLEGE cannot
provideaccess and provides individual with the reasons for the delay and the date when access may be
granted. PHI shall be provided in the form and format requested by the individual or COUNTY.
COLLEGE shall make any amendment(s)to PHI in a designated record set at the
request of COUNTY or individual,and in the time and manner designated by COUNTY in accordance
with 45 CFR Section 164.526.
COLLEGE shall provide to COUNTY or to an individual,in a time and manner
designatedby COUNTY, information collected in accordance with 45 CFR Section 164.528,to permit
COUNTY to respond to a request by the individual for an accounting of disclosures of PHI in
accordance with 45 CFR Section 164.528.
G.COLLEGE shall report to COUNTY,in writing,any knowledge or reasonable
belief that there has been unauthorized access, viewing, use, disclosure,security incident, or breach of
unsecuredPHI not permitted by this Agreement of which it becomes aware, immediatelyand without
reasonabledelay and in no case later than two (2) business days of discovery. Immediate notification
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shall be made to COUNTY'S Information Security Officer and Privacy Officer and COUNTY'S DPH
HIPAA Representative,within two (2)business days of discovery.The notification shall include, to
the extent possible,the identification of each individual whose unsecured PHI has been,or is
reasonably believed to have been,accessed,acquired,used,disclosed,or breached.COLLEGE shall
take prompt corrective action to cure any deficiencies and any action pertaining to such unauthorized
disclosure required by applicable Federal and State Laws and regulations.COLLEGE shall
investigate such breach and is responsible for all notifications required by law and regulation or
deemed necessary by COUNTY and shall provide a written report of the investigation and reporting
required to COUNTY'S Information Security Officer and Privacy Officer and COUNTY'S DPH
HIPAA Representative.This written investigation and description of any reporting necessary shall be
postmarked within the thirty (30)working days of the discovery of the breach to the addresses below:
County of Fresno County of Fresno County of Fresno
Dept.of Public Health Dept.of Public Health Information Technology Services
HIPAA Representative Privacy Officer Information Security Officer
(559)600-6439 (559)600-6402 (559)600-5805
P.O.Box 11867 P.O.Box 11867 2048 N.Fine Street
Fresno,CA 93775 Fresno,CA 93775 Fresno,CA 93727
H.COLLEGE shall make its internal practices,books,and records relating to the
use and disclosure of PHI received from COUNTY,or created or received by the COLLEGE on
behalf of COUNTY,in compliance with HIPAA's Privacy Rule,including,but not limited to the
requirements set forth in Title 45, CFR,Sections 160 and 164.COLLEGE shall make its internal
practices,books,and records relating to the use and disclosure of PHI received from COUNTY,or
created or received by the COLLEGE on behalf of COUNTY,available to the United States
Department of Health and Human Services (Secretary)upon demand.
COLLEGE shall cooperate with the compliance and investigation reviews
conducted by the Secretary. PHI access to the Secretary must be provided during the COLLEGE'S
normal business hours,however,upon exigent circumstances access at any time must be granted.
Upon the Secretary's compliance or investigation review,if PHI is unavailable to COLLEGE and in
possession of a Subcontractor,it must certify efforts to obtain the information to the Secretary.
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I.Safeguards
COLLEGE shall implement administrative,physical, and technical safeguards as
required by the HIPAA Security Rule,Subpart C of 45 CFR 164,that reasonably and appropriately
protect the confidentiality, integrity, and availability of PHI, including electronic PHI, that it creates,
receives, maintains or transmits on behalf of COUNTY and to prevent unauthorized access, viewing,
use, disclosure, or breach of PHI other than as provided for by this Agreement.COLLEGE shall
conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the
confidential,integrity and availability of electronic PHI.COLLEGE shall develop and maintain a
written information privacy and security program that includes administrative,technical and physical
safeguards appropriate to the size and complexity of COLLEGE'S operations and the nature and scope
of its activities. Upon COUNTY'S request,COLLEGE shall provide COUNTY with information
concerning such safeguards.
COLLEGE shall implement strong access controls and other security safeguards
and precautions in order to restrict logical and physical access to confidential,personal (e.g., PHI) or
sensitive data to authorized users only. Said safeguards and precautions shall include the following
administrative and technical password controls for all systems used to process or store confidential,
personal,or sensitive data:
1.Passwords must not be:
a.Shared or written down where they are accessible or recognizable
by anyone else; such as taped to computer screens,stored under keyboards,or visible in a work area;
b. A dictionary word; or
c.Stored in clear text
2.Passwords must be:
a.Eight (8)characters or more in length;
b.Changed every ninety (90) days;
c.Changed immediately if revealed or compromised;and
d.Composed of characters from at least three (3)of the
following four (4)groups from the standard keyboard:
16 -COUNTY OF FRESNO
F'resno,CA
1)Upper case letters (A-Z);
2)Lowercase letters (a-z);
3)Arabic numerals (0 through 9); and
4)Non-alphanumeric characters (punctuation
symbols).
COLLEGE shall implement the following security controls on each workstation
or portable computing device (e.g., laptop computer)containing confidential,
personal,or sensitive data:
1.Network-based firewall and/or personal firewall;
2.Continuously updated anti-virus software;and
3. Patch management process including installation of all operating
system/software vendor security patches.
COLLEGE shall utilize a commercial encryption solution that has received FIPS
140-2 validation to encrypt all confidential,personal, or sensitive data stored on portable electronic
media (including,but not limited to, compact disks and thumb drives) and on portable computing
devices (including,but not limited to, laptop and notebook computers).
COLLEGE shall not transmit confidential,personal,or sensitive data via e-mail
or other internet transport protocol unless the data is encrypted by a solution that has been validatedby
the National Institute of Standards and Technology (NIST) as conforming to the Advanced Encryption
Standard(AES) Algorithm. COLLEGE must apply appropriate sanctions against its employeeswho
fail to complywith these safeguards. COLLEGE must adopt procedures for terminating accessto PHI
when employment of employee ends.
J.Mitigation of Harmful Effects
COLLEGE shall mitigate,to the extent practicable,any harmful effect that is
suspected or known to COLLEGE of an unauthorized access, viewing, use, disclosure, or breach of
PHI by COLLEGE or its subcontractors in violation of the requirements of these provisions.
COLLEGE must document suspected or known harmful effects and the outcome.
///
17 -COUN'lY OF F'RESNO
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K.COLLEGE'S Subcontractors
COLLEGE shall ensure that any of its contractors,including subcontractors,if
applicable, to whom COLLEGE provides PHI received from or created or received by COLLEGE on
behalf of COUNTY, agree to the same restrictions, safeguards, and conditions that apply to
COLLEGE with respect to such PHI and to incorporate, when applicable, the relevant provisions of
these provisions into each subcontract or sub-award to such agents or subcontractors..
L.Employee Training and Discipline
COLLEGE shall train and use reasonable measures to ensure compliance with
the requirements of these provisions by employees who assist in the performance of functions or
activities on behalf of COUNTY under this Agreement and use or disclose PHI and discipline such
employees who intentionally violate any provisions of these provisions,including termination of
employment.
M.Termination for Cause
Upon COUNTY'S knowledge of a material breach of these provisions by
COLLEGE,COUNTY shall either:
1.Provide an opportunity for COLLEGE to cure the breach or end the
violation and terminate this Agreement if COLLEGE does not cure the breach or end the violation
within the time specified by COUNTY;or
2.Immediately terminate this Agreement if COLLEGE has breached a
material term of these provisions and cure is not possible.
3.If neither cure nor termination is feasible, the COUNTY'S Privacy
Officer shall report the violation to the Secretary of the U.S.Department of Health and Human
Services.
N.Judicial or Administrative Proceedings
COUNTY may terminate this Agreement in accordance with the terms and
conditions of this Agreement as written hereinabove, if: (1)COLLEGE is found guilty in a criminal
proceeding for a violation of the HIPAA Privacy or Security Laws or the HITECH Act; or (2) there is
a findingor stipulation that the COLLEGE has violated a privacy or security standard or requirement
COUN'IY OF FRESNO
F'resno,CA
ofthe HITECH Act,HIPAAor othersecurityorprivacylawsinan administrative or civil proceeding
in which the COLLEGE is a party.
O.Effect of Termination
Upon termination or expiration of this Agreement for any reason, COLLEGE
shall return or destroy all PHI received from COUNTY (or created or received by COLLEGE on
behalfof COUNTY) that COLLEGE still maintains in any form, and shall retain no copies of such
PHI. If return or destruction of PHI is not feasible, it shall continue to extend the protections of these
provisions to such information, and limit further use of such PHI to those purposes that make the
return or destruction of such PHI infeasible. This provision shall apply to PHI that is in the possession
of subcontractors or agents, if applicable,of COLLEGE. If COLLEGE destroys the PHI data, a
certification of date and time of destruction shall be provided to the COUNTY by COLLEGE.
P.Disclaimer
COUNTY makes no warranty or representation that compliance by COLLEGE
with these provisions, the HITECH Act, HIPAA or the HIPAA regulations will be adequate or
satisfactory for COLLEGE'S own purposes or that any information in COLLEGE'S possession or
control, or transmitted or received by COLLEGE,is or will be secure from unauthorized access,
viewing, use, disclosure, or breach. COLLEGE is solely responsible for all decisions made by
COLLEGE regarding the safeguarding of PHI.
Q.Amendment
The parties acknowledge that Federal and State laws relating to electronic data
security and privacy are rapidly evolving and that amendment of these provisions may be required to
provide for procedures to ensure compliance with such developments. The parties specificallyagree
to take such action as is necessary to amend this agreement in order to implement the standards and
requirements of HIPAA, the HIPAA regulations, the HITECH Act and other applicable laws relating
to the security or privacy of PHI.COUNTY may terminate this Agreement upon thirty (30) days
written notice in the event that COLLEGE does not enter into an amendment providing assurances
regarding the safeguarding of PHI that COUNTY in its sole discretion, deems sufficient to satisfy the
standards and requirements of HIPAA,the HIPAA regulations and the HITECH Act.
-19 -COUNTY OF FRESNO
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R.No Third-Party Beneficiaries
Nothing express or implied in the terms and conditions of these provisions is
intended to confer, nor shall anything herein confer, upon any person other than COUNTY or
COLLEGE andtheir respective successorsor assignees,any rights, remedies, obligationsor liabilities
whatsoever.
S.Interpretation
The terms and conditions in these provisions shall be interpreted as broadlyas
necessaryto implement and comply with HIPAA, the HIPAA regulations and applicable State laws.
The parties agree that any ambiguity in the terms and conditions of these provisions shall be resolved
in favor of a meaning that complies and is consistent with HIPAA and the HIPAA regulations.
T.Regulatory References
A reference in the terms and conditions of these provisions to a section in the
HIPAA regulations means the section as in effect or as amended.
U.Survival
The respective rights and obligations of COLLEGE as stated in this Section shall
survive the termination or expiration of this Agreement.
V.No Waiver of Obligations
No change, waiver or discharge of any liability or obligation hereunder on any
one or moreoccasions shall be deemed a waiver of performance of any continuing or other obligation,
or shall prohibit enforcement of any obligation on any other occasion.
15.DATA SECURITY
For the purpose of preventing the potential loss,misappropriation or inadvertent
disclosure of COUNTY data including sensitive or personal client information;abuse of COUNTY
resources; and/or disruption to COUNTY operations,individuals and/or agencies that enter into a
contractual relationship with the COUNTY for the purpose of providing services under this
Agreement must employ adequate data security measures to protect the confidential information
provided to the COLLEGE by the COUNTY, including but not limited to the following:
///
20 -COUN'IY OF FRESNO
F'resno,CA
A.COLLEGE-Owned Mobile,Wireless,or Handheld Devices
COLLEGE may not connect to COUNTY networks via personally-owned
mobile, wireless or handheld devices except: 1) when authorized by COUNTY for telecommuting
purposes; 2) if virus protection software currency agreements are in place; 3) if a mobile device has
the remote wipe feature enabled;and 4) a secure connection is used.
B.COLLEGE-Owned Computers or Computer Peripherals
COLLEGE may not bring COLLEGE-owned computers or computer peripherals
into the COUNTY for use without prior authorization from the COUNTY'S Chief Information Officer,
or designee(s), including but not limited to mobile storage devices.If approved to be transferred, data
must be stored on a secure server approved by the COUNTY and transferred by means of a virtual
privatenetwork (VPN) connection or another type of secure connection. Said data must be encrypted.
C.COUNTY-Owned Computer Equipment
COLLEGE,or anyone having an employment relationship with the COUNTY,
may not use COUNTY computers or computer peripherals on non-COUNTY premises without prior
authorization from COUNTY'S Chief Information Officer, or designee(s).
D.COLLEGE may not store COUNTY'S private,confidential or sensitive data on
any hard-disk drive,portable storage device, or remote storage installation unless encrypted.
E.COLLEGE shall be responsible to employ strict controls to ensure the integrity
and security of the COUNTY'S confidential information and to prevent unauthorized access viewing,
use or disclosure of data maintained in computer files, program documentation,data processing
systems,data files and data processing equipment which stores or processes COUNTY data internally
and externally.
F.Confidential client information transmitted to one party by the other by means of
electronic transmissions must be encrypted according to Advanced Encryption Standards (AES)of
128 BIT or higher.Additionally,a password or pass phrase must be utilized.
G.COLLEGE shall be responsible to immediately notify COUNTY of any
violations, breaches or potential breaches of security related to COUNTY'S confidential information,
21 -COUN'IY OF F'RESNO
I''resno,CA
data maintained incomputerfiles,program documentation,dataprocessing systems,data files and
data processing equipment whichstoresor processes COUNTY data internallyor externally.
H.COUNTY shall provide oversight to COLLEGE'S response to all incidents
arising from a possible breach of security related to COUNTY'S confidential client information
providedto COLLEGE; however, COLLEGE will be responsible to issue any notification to affected
individuals as required by law or as deemed necessary by COUNTY in its sole discretion.COLLEGE
will be responsible for all costs incurred as a result of providing said required notification.
16-NON-DISCRIMINATION
During the performance of this Agreement COLLEGE shall not unlawfully discriminate
againstanyemployeeor applicant for employment,or recipient of services, becauseof race,religion,
color, nationalorigin, ancestry, physical disability, mental disability, medical condition, genetic
information,maritalstatus, sex, gender,genderidentity, genderexpression, age, sexual orientation,or
military and veteran status,pursuant to all applicable State of California and Federal statutes and
regulations. This non-discrimination policy covers admission and access to and treatment and
employment in the COLLEGE'S programs and activities, including occupational education.
17.CONFLICT OF INTEREST
No officer, agent, or employee of the COUNTY who exercises any function or
responsibilityfor planning and carrying out the services provided under this Agreement shall haveany
direct or indirect personal financial interest in this Agreement. The COLLEGE shall comply withall
Federal, State of California, and local conflict of interest laws, statutes, and regulations, which shall be
applicableto all parties and beneficiaries under this Agreement and any officer, agent, or employee of
the COUNTY.
18.COMPLIANCE
COLLEGE agrees to comply with the COUNTY'S Contractor Code of Conduct and
Ethicsandthe COUNTY'SComplianceProgramin accordancewith Exhibit C, attachedheretoandby
this referenceincorporated herein. Within thirty (30) days of entering into the agreement with the
COUNTY,COLLEGE shall have all of COLLEGE'S employees, agents and subcontractors providing
services under this Agreement certify in writing, that he or she has received,read, understood, and
22 -COUN'IY OF FRESNO
F'resno,CA
shall abide bythe Contractor Codeof Conduct and Ethics.COLLEGE shall ensure that within thirty
(30) days of hire, all new employees, agents and subcontractors providing services under this
Agreement shallcertify in writingthat he or she has received,read, understood, and shallabidebythe
"ContractorCodeof Conduct and Ethics" by reading and signing the "Contractor Acknowledgement
andAgreement,"both provided in Exhibit C. COLLEGEunderstandsthat the promotionof and
adherenceto the Code of Conduct is an element in evaluating the performance of COLLEGE and its
employees,agents and subcontractors
Within thirty (30) days of entering into this Agreement, and annually thereafter, all
employees,agents and subcontractors providing services under this Agreement shall complete general
compliance training.All new employees,agentsand subcontractorsshall attend the appropriate
training within thirty (30) days of hire. Each individual who is required to attend training shall certify
in writingthat he or she has receivedthe requiredtraining. The certification shall specifythe typeof
training received and the date received. The certification shall be provided to the COUNTY'S
ComplianceOfficer at 3133 N. Millbrook Avenue, Fresno, CA 93703. COLLEGE agrees to
reimburseCOUNTY for the entire cost of any penalty imposed upon COUNTY by the Federal
Government as a result of COLLEGE'S violation of the terms of this Agreement.
19.COMPLIANCE WITH STATE REQUIREMENTS
COLLEGE recognizes that COUNTY operates its mental health system under an
agreement with the State of California Department of Mental Health, and that under said agreement
the State of California imposes certain requirements on the COUNTY and its subcontractors.
COLLEGE shall adhere to all State of California requirements, including those identified in Exhibit C,
attached hereto and by this reference incorporated herein.
20.DISCLOSURE OF SELF-DEALING TRANSACTIONS
This provision is onlyapplicableif COLLEGEis operatingas a corporation(a for-profit
or non-profitcorporation) or if during the term of this agreement, COLLEGE changes its statusto
operate as a corporation.
Members of COLLEGE'S Board of Directors shall disclose any self-dealing transactions
thattheyarea partyto while COLLEGEis providinggoodsor performing servicesunderthis
23 -COUNTY OF FRESNO
F'resno,CA
agreement.A self-dealingtransaction shall meana transactionto which COLLEGE is a partyand in
which one or more of its directors has a material financial interest.Members of the Board of Directors
shall disclose any self-dealing transactions that they are a party to by completing and signing a "Self-
Dealing Transaction Disclosure Form" (Exhibit D) attached hereto and by this reference incorporated
herein.COLLEGE shall submit the "Self-Dealing Transaction Disclosure Form to the COUNTY
prior to commencing with the self-dealing transaction or immediately thereafter.
21.AUDITS AND INSPECTIONS
COLLEGE shall at any time during business hours, and as often as COUNTY may deem
necessary, make available to COUNTY for examination all of its records and data with respect to the
matters covered by this Agreement. COLLEGE shall, upon request by COUNTY, permit COUNTY
to audit and inspect all such records and data necessary to ensure COLLEGE'S compliance with the
terms of this Agreement.
If this Agreement exceeds Ten Thousand and No/100 Dollars ($10,000.00),COLLEGE
shall be subject to the examination and audit of the State Auditor General for a period of three (3)
years after final payment under contract (Government Code section 8546.7).
22.NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY COLLEGE
Director,Fresno County President
Department of Behavioral Health San Joaquin Valley College
3133 N.Millbrook Avenue 3828 W.Caldwell Avenue
Fresno,CA 93703 Visalia,CA 93277
Director,Fresno County
Department of Public Health
P.O.Box 11867
Fresno,CA 93775
Any and all notices between COUNTY and COLLEGE provided for or permitted under
this Agreement or by law shall be in writing and shall be deemed duly served when personally
delivered to one of the parties,or in lieu of such personal service, when deposited in the United States
-24 -COUN'IY OF FRESNO
F'resno,CA
Mail, postage prepaid,addressed to such party.
23.GOVERNING LAW
Venue for any action arising out of or related to this Agreement shall only be in Fresno
County,California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
24.SEVERABILITY
The provisions of this Agreement are severable. The invalidity or unenforceability of
any one provision of the Agreement shall not affect the other provisions.
25.ENTIRE AGREEMENT
This Agreement, including all Exhibits, constitutes the entire agreement between
COLLEGE and COUNTY with respect to the subject matter hereof and supersedes all previous
agreementnegotiations, proposals, commitments, writings, advertisements, publications, and
understandings of any nature whatsoever unless expressly included in this Agreement.
///
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2 5 -COUN'IY OF FRESNO
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IN WI1NESS WHEREOF, the parties hereto have executed this Agreement as of the day and
year first hereinabove written.
ATTEST:
COLLEGE:
SAN JOAQUIN VALLEY COLLEGE
-~
B
Chairman of the Board, or
President, or any Vice President
By-------""'--~~· ----==--=--=---£--=--~----"'-~--=--
Print Name: tf1w Mo
Title: (..-/:0 · ---=--------------------Secretary (of Corporation), or
any Assistant Secretary, or
ChiefFinancial Officer, or
any Assistant Treasurer
Mailing Address:
3828 W. Caldwell Avenue
Visalia, CA 93277
Phone No.: (559) 734-9000
Contact: President
COUNTY OF FRESNO
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By~ ~sb9¥J
Date: YY\~ \£1, ()..01~
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
-26 -COUNTY OF FRESNO
Fresno,CA
APPROVED AS TO LEGAL FORM:
DANIEL C.CEDERBORG,COUNTY COUNSEL
By
APPROVED AS TO ACCOUNTING FORM:
VICKI CROW,C.P.A.,AUDITOR-CONTROLLER/
TREASURER-TAX COLLECTOR
By -{'id^m y
REVIEWED AND RECOMMENDED
FOR APPROVAL:
By £HUJM~<i~IjJcCAlAJ^"
Dawan Utecht,Director
Department of Behavioral Health
REVIEWED AND RECOMMENDED
FOR APPROVAL:
David Pomaville
Director
Department of Public Health
Fund/Subclass:
Account:
Organizations:
[em]
0001/10000
5800
56201500
56302999
-27 -COUN'IY OF F'RESNO
Fresno,CA
Occupational Safety and Health Admin.,Labor §1910.1030
Appendix B to §1910.1029—Industrial Hy
giene AND MEDICAL SURVEILLANCE GUIDE
LINES
I.INDUSTRIAL HYGIENE GUIDELINES
A.Sampling (Benzene-Soluble Fraction
Total Particulate Matter).
Samples collected should be full shift (at
least 7-hour)samples.Sampling should be
done using a personal sampling pump with
pulsation damper at a flow rate of 2 liters
per minute.Samples should be collected on
0.8 micrometer pore size silver membrane fil
ters (37 mm diameter)preceded by Gelman
glass fiber type A-E filters encased in three-
piece plastic (polystyrene)field monitor cas
settes.The cassette face cap should be on
and the plug removed.The rotameter should
be checked every hour to ensure that proper
flow rates are maintained.
A minimum of three full-shift samples
should be collected for each job classifica
tion on each battery,at least one from each
shift.If disparate results are obtained for
particular job classification,sampling
should be repeated.It is advisable to sample
each shift on more than one day to account
for environmental variables (wind,precipita
tion,etc.)which may affect sampling.Dif
ferences in exposures among different work
shifts may indicate a need to improve work
practices on a particular shift.Sampling re
sults from different shifts for each job classi
fication should not be averaged.Multiple
samples from same shift on each battery
may be used to calculate an average expo
sure for a particular job classification.
B.Analysis.
1.All extraction glassware is cleaned with
dichromic acid cleaning solution,rinsed with
tap water,then dionized water,acetone,and
allowed to dry completely.The glassware is
rinsed with nanograde benzene before use.
The Teflon cups are cleaned with benzene
then with acetone.
2.Pre-weigh the 2 ml Teflon cups to one
hundredth of a milligram (0.01 mg)on an
autobalance AD 2 Tare weight of the cups is
about 50 mg.
3.Place the silver membrane filter and
glass fiber filter into a 15 ml test tube.
4.Extract with 5 ml of benzene for five
minutes in an ultrasonic cleaner.
5.Filter the extract in 15 ml medium glass
fritted funnels.
6.Rinse test tube and filters with two 1.5
ml aliquots of benzene and filter through the
fritted glass funnel.
7.Collect the extract and two rinses in a 10
ml Kontes graduated evaporative concen
trator.
8.Evaporate down to 1 ml while rinsing the
sides with benzene.
9.Pipet 0.5 ml into the Teflon cup and
evaporate to dryness in a vacuum oven at 40
°C for 3 hours.
10.Weigh the Teflon cup and the weight
gain is due to the benzene soluble residue in
half the Sample.
II.MEDICAL SURVEILLANCE GUIDELINES
A.General.The minimum requirements for
the medical examination for coke oven
workers are given in paragraph (j)of the
standard.The initial examination is to be
provided to all coke oven workers who work
at least 30 days in the regulated area.The
examination includes a 14" x 17"posterior-an
terior chest x-ray reading,pulmonary func
tion tests (FVC and FEV 1.0),weight,urinal
ysis,skin examination,and a urinary
cytologic examination.These tests are need
ed to serve as the baseline for comparing the
employee's future test results.Periodic
exams include all the elements of the initial
exam,except that the urine cytologic test is
to be performed only on those employees
who are 45 years or older or who have worked
for 5 or more years in the regulated area;
periodic exams,with the exception of x-rays,
are to be performed semiannually for this
group instead of annually;for this group,x-
rays will continue to be given at least annu
ally.The examination contents are min
imum requirements;additional tests such as
lateral and oblique x-rays or additional pul
monary function tests may be performed if
deemed necessary.
B.Pulmonary function tests.
Pulmonary function tests should be per
formed in a manner which minimizes subject
and operator bias.There has been shown to
be learning effects with regard to the results
obtained from certain tests,such as FEV 1.0.
Best results can be obtained by multiple
trials for each subject.The best of three
trials or the average of the last three of five
trials may be used in obtaining reliable re
sults.The type of equipment used (manufac
turer,model,etc.)should be recorded with
the results as reliability and accuracy varies
and such information may be important in
the evaluation of test results.Care should be
exercised to obtain the best possible testing
equipment.
[39 FR 23502,June 27, 1974, 41 FR 46784,Oct.
22.1976,as amended at 42 FR 3304,Jan.18,
1977; 45 FR 35283,May 23, 1980; 50 FR 37353.
37354,Sept.13, 1985; 54 FR 24334.June 7, 1989;
61 FR 5508,Feb.13,1996;63 FR 1290,Jan.8,
1998;63 FR 33468,June 18,1998;70 FR 1142,
Jan.5.2005; 71 FR 16672,16673.Apr.3, 2006; 71
FR 50189,Aug.24,2006]
§1910.1030 Bloodborne pathogens.
(a)Scope and Application.This section
applies to all occupational exposure to
blood or other potentially infectious
materials as defined by paragraph (b)
of this section.
265
Exhibit A
Page 1 of 14
§1910.1030
(b)Definitions.For purposes of this
section,the following shall apply:
Assistant Secretary means the Assist
ant Secretary of Labor for Occupa
tional Safety and Health,or designated
representative.
Blood means human blood,human
blood components,and products made
from human blood.
Bloodborne Pathogens means patho
genic 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 immuno
deficiency virus (HIV).
Clinical Laboratory means a work
place where diagnostic or other screen
ing procedures are performed on blood
or other potentially infectious mate
rials.
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 con
taminated 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 des
ignated representative.
Engineering controls means controls
(e.g.,sharps disposal containers,self-
sheathing needles,safer medical de
vices,such as sharps with engineered
sharps injury protections and
needleless systems)that isolate or re
move the bloodborne pathogens hazard
from the workplace.
Exposure Incident means a specific
eye,mouth,other mucous membrane,
non-intact skin,or parenteral contact
29 CFR Ch.XVII (7-1-07 Edition)
with blood or other potentially infec
tious materials that results from the
performance of an employee's duties.
Handwashing Facilities means a facil
ity 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 inde
pendently perform the activities re
quired by paragraph (f)Hepatitis B
Vaccination and Post-exposure Evalua
tion and Follow-up.
HBV means hepatitis B 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 contami
nated sharps.
Occupational Exposure means reason
ably 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,cerebro
spinal fluid,synovial fluid,pleural
fluid,pericardial fluid,peritoneal fluid,
amniotic fluid,saliva in dental proce
dures,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 cul
tures,organ cultures,and HIV-or
HBV-containing culture medium or
other solutions;and blood,organs,or
other tissues from experimental ani
mals infected with HIV or HBV.
Parenteral means piercing mucous
membranes or the skin barrier through
266
Exhibit A
Page 2 of 14
Occupational Safety and Health Admin.,Labor §1910.1030
such events as needlesticks,human
bites,cuts,and abrasions.
Personal Protective Equipment is spe
cialized clothing or equipment worn by
an employee for protection against a
hazard.General work clothes (e.g.,uni
forms,pants,shirts or blouses)not in
tended 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-vol
ume 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 com
pressed;items that are caked with
dried blood or other potentially infec
tious materials and are capable of re
leasing these materials during han
dling;contaminated sharps:and patho
logical and microbiological wastes con
taining blood or other potentially in
fectious materials.
Research Laboratory means a labora
tory producing or using research-lab
oratory-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 nonneedle 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 indi
vidual,living or dead,whose blood or
other potentially infectious materials
may be a source of occupational expo
sure to the employee.Examples in
clude,but are not limited to,hospital
and clinic patients;clients in institu
tions for the developmentally disabled;
trauma victims;clients of drug and al
cohol treatment facilities;residents of
hospices and nursing homes;human re
mains;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 resist
ant 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 in
fectious for HIV,HBV,and other
bloodborne 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 recap
ping of needles by a two-handed tech
nique).
(c)Exposure control—(1)Exposure Con
trol Plan,(i)Each employer having an
employee(s)with occupational expo
sure as defined by paragraph (b)of this
section shall establish a written Expo
sure Control Plan designed to elimi
nate or minimize employee exposure.
(ii)The Exposure Control Plan shall
contain at least the following ele
ments:
(A)The exposure determination re
quired by paragraph(c)(2),
(B)The schedule and method of im
plementation for paragraphs (d)Meth
ods of Compliance,(e)HIV and HBV
Research Laboratories and Production
Facilities,(f)Hepatitis B Vaccination
and Post-Exposure Evaluation and Fol
low-up,(g)Communication of Hazards
to Employees,and (h)Recordkeeping,
of this standard,and
(C)The procedure for the evaluation
of circumstances surrounding exposure
incidents as required by paragraph
(f)(3)(i)of this standard.
(iii)Each employer shall ensure that
a copy of the Exposure Control Plan is
accessible to employees in accordance
with 29 CFR 1910.20(e).
(iv)The Exposure Control Plan shall
be reviewed and updated at least annu
ally and whenever necessary to reflect
new or modified tasks and procedures
which affect occupational exposure and
to reflect new or revised employee po
sitions with occupational exposure.
The review and update of such plans
shall also:
(A)Reflect changes in technology
that eliminate or reduce exposure to
bloodborne pathogens;and
(B)Document annually consideration
and implementation of appropriate
commercially available and effective
267
Exhibit A
Page 3 of 14
§1910.1030
safer medical devices designed to elimi
nate or minimize occupational expo
sure.
(v)An employer,who is required to
establish an Exposure Control Plan
shall solicit input from non-managerial
employees responsible for direct pa
tient care who are potentially exposed
to injuries from contaminated sharps
in the identification,evaluation,and
selection of effective engineering and
work practice controls and shall docu
ment the solicitation in the Exposure
Control Plan.
(vi)The Exposure Control Plan shall
be made available to the Assistant Sec
retary and the Director upon request
for examination and copying.
(2)Exposure determination,(i)Each
employer who has an employee(s)with
occupational exposure as defined by
paragraph (b)of this section shall pre
pare an exposure determination.This
exposure determination shall contain
the following:
(A) A list of all job classifications in
which all employees in those job classi
fications have occupational exposure;
(B) A list of job classifications in
which some employees have occupa
tional exposure,and
(C) A list of all tasks and procedures
or groups of closely related task and
procedures in which occupational expo
sure occurs and that are performed by
employees in job classifications listed
in accordance with the provisions of
paragraph (c)(2)(i)(B)of this standard.
(ii)This exposure determination
shall be made without regard to the
use of personal protective equipment.
(d)Methods of compliance—(1)General.
Universal precautions shall be observed
to prevent contact with blood or other
potentially infectious materials.Under
circumstances in which differentiation
between body fluid types is difficult or
impossible,all body fluids shall be con
sidered potentially infectious mate
rials.
(2)Engineering and work practice con
trols,(i)Engineering and work practice
controls shall be used to eliminate or
minimize employee exposure.Where
occupational exposure remains after
institution of these controls,personal
protective equipment shall also be
used.
29 CFR Ch.XVII (7-1-07 Edition)
(ii)Engineering controls shall be ex
amined and maintained or replaced on
a regular schedule to ensure their ef
fectiveness.
(iii)Employers shall provide
handwashing facilities which are read
ily accessible to employees.
(iv)When provision of handwashing
facilities is not feasible,the employer
shall provide either an appropriate an
tiseptic hand cleanser in conjunction
with clean cloth/paper towels or anti
septic towelettes.When antiseptic
hand cleansers or towelettes are used,
hands shall be washed with soap and
running water as soon as feasible.
(v)Employers shall ensure that em
ployees wash their hands immediately
or as soon as feasible after removal of
gloves or other personal protective
equipment.
(vi)Employers shall ensure that em
ployees wash hands and any other skin
with soap and water,or flush mucous
membranes with water immediately or
as soon as feasible following contact of
such body areas with blood or other po
tentially infectious materials.
(vii)Contaminated needles and other
contaminated sharps shall not be bent,
recapped,or removed except as noted
in paragraphs (d)(2)(vii)(A)and
(d)(2)(vii)(B)below.Shearing or break
ing of contaminated needles is prohib
ited.
(A)Contaminated needles and other
contaminated sharps shall not be bent,
recapped or removed unless the em
ployer can demonstrate that no alter
native is feasible or that such action is
required by a specific medical or dental
procedure.
(B)Such bending,recapping or needle
removal must be accomplished through
the use of a mechanical device or a
one-handed technique.
(viii)Immediately or as soon as pos
sible after use,contaminated reusable
sharps shall be placed in appropriate
containers until properly reprocessed.
These containers shall be:
(A)Puncture resistant;
(B)Labeled or color-coded in accord
ance with this standard;
(C)Leakproof on the sides and bot
tom;and
(D)In accordance with the require
ments set forth in paragraph
(d)(4)(ii)(E)for reusable sharps.
268
Exhibit A
Page 4 of 14
Occupational Safety and Health Admin.,Labor §1910.1030
(ix)Eating,drinking,smoking,ap
plying cosmetics or lip balm,and han
dling contact lenses are prohibited in
work areas where there is a reasonable
likelihood of occupational exposure.
(x)Food and drink shall not be kept
in refrigerators,freezers,shelves,cabi
nets or on countertops or benchtops
where blood or other potentially infec
tious materials are present.
(xi)All procedures involving blood or
other potentially infectious materials
shall be performed in such a manner as
to minimize splashing,spraying,spat
tering,and generation of droplets of
these substances.
(xii)Mouth pipetting/suctioning of
blood or other potentially infectious
materials is prohibited.
(xiii)Specimens of blood or other po
tentially infectious materials shall be
placed in a container which prevents
leakage during collection,handling,
processing,storage,transport,or ship
ping.
(A)The container for storage,trans
port,or shipping shall be labeled or
color-coded according to paragraph
(g)(1)(i)and closed prior to being
stored,transported,or shipped.When a
facility utilizes Universal Precautions
in the handling of all specimens,the
labeling/color-coding of specimens is
not necessary provided containers are
recognizable as containing specimens.
This exemption only applies while such
specimens/containers remain within
the facility.Labeling or color-coding
in accordance with paragraph (g)(1) (i)
is required when such specimens/con
tainers leave the facility.
(B)If outside contamination of the
primary container occurs,the primary
container shall be placed within a sec
ond container which prevents leakage
during handling,processing,storage,
transport,or shipping and is labeled or
color-coded according to the require
ments of this standard.
(C)If the specimen could puncture
the primary container,the primary
container shall be placed within a sec
ondary container which is puncture-re
sistant in addition to the above charac
teristics.
(xiv)Equipment which may become
contaminated with blood or other po
tentially infectious materials shall be
examined prior to servicing or shipping
and shall be decontaminated as nec
essary,unless the employer can dem
onstrate that decontamination of such
equipment or portions of such equip
ment is not feasible.
(A) A readily observable label in ac
cordance with paragraph (g)(1)(i)(H)
shall be attached to the equipment
stating which portions remain con
taminated.
(B)The employer shall ensure that
this information is conveyed to all af
fected employees,the servicing rep
resentative,and/or the manufacturer,
as appropriate,prior to handling,serv
icing,or shipping so that appropriate
precautions will be taken.
(3)Personal protective equipment—(i)
Provision.When there is occupational
exposure,the employer shall provide,
at no cost to the employee,appropriate
personal protective equipment such as,
but not limited to,gloves,gowns,lab
oratory coats,face shields or masks
and eye protection,and mouthpieces,
resuscitation bags,pocket masks,or
other ventilation devices.Personal
protective equipment will be consid
ered "appropriate"only if it does not
permit blood or other potentially infec
tious materials to pass through to or
reach the employee's work clothes,
street clothes,undergarments,skin,
eyes,mouth,or other mucous mem
branes under normal conditions of use
and for the duration of time which the
protective equipment will be used.
(ii)Use.The employer shall ensure
that the employee uses appropriate
personal protective equipment unless
the employer shows that the employee
temporarily and briefly declined to use
personal protective equipment when,
under rare and extraordinary cir
cumstances,it was the employee's pro
fessional judgment that in the specific
instance its use would have prevented
the delivery of health care or public
safety services or would have posed an
increased hazard to the safety of the
worker or co-worker.When the em
ployee makes this judgement,the cir
cumstances shall be investigated and
documented in order to determine
whether changes can be instituted to
prevent such occurences in the future.
(iii)Accessibility.The employer shall
ensure that appropriate personal pro
tective equipment in the appropriate
269
Exhibit A
Page 5 of 14
§1910.1030
sizes is readily accessible at the work
site or is issued to employees.
Hypoallergenic gloves,glove liners,
powderless gloves,or other similar al
ternatives shall be readily accessible to
those employees who are allergic to the
gloves normally provided.
(iv)Cleaning.Laundering,and Dis
posal.The employer shall clean,laun
der,and dispose of personal protective
equipment required by paragraphs (d)
and (e)of this standard,at no cost to
the employee.
(v)Repair and Replacement.The em
ployer shall repair or replace personal
protective equipment as needed to
maintain its effectiveness,at no cost
to the employee.
(vi) If a garment(s)is penetrated by
blood or other potentially infectious
materials,the garment(s)shall be re
moved immediately or as soon as fea
sible.
(vii)All personal protective equip
ment shall be removed prior to leaving
the work area.
(viii)When personal protective equip
ment is removed it shall be placed in
an appropriately designated area or
container for storage,washing,decon
tamination or disposal.
(ix)Gloves.Gloves shall be worn when
it can be reasonably anticipated that
the employee may have hand contact
with blood,other potentially infectious
materials,mucous membranes,and
non-intact skin;when performing vas
cular access procedures except as speci
fied in paragraph (d)(3)(ix)(D);and
when handling or touching contami
nated items or surfaces.
(A)Disposable (single use)gloves
such as surgical or examination gloves,
shall be replaced as soon as practical
when contaminated or as soon as fea
sible if they are torn,punctured,or
when their ability to function as a bar
rier is compromised.
(B)Disposable (single use)gloves
shall not be washed or decontaminated
for re-use.
(C)Utility gloves may be decontami
nated for re-use if the integrity of the
glove is not compromised.However,
they must be discarded if they are
cracked,peeling,torn,punctured,or
exhibit other signs of deterioration or
when their ability to function as a bar
rier is compromised.
29 CFR Ch.XVII (7-1-07 Edition)
(D) If an employer in a volunteer
blood donation center judges that rou
tine gloving for all phlebotomies is not
necessary then the employer shall:
(1)Periodically reevaluate this pol
icy;
(2)Make gloves available to all em
ployees who wish to use them for phle
botomy;
(3)Not discourage the use of gloves
for phlebotomy;and
(4)Require that gloves be used for
phlebotomy in the following cir
cumstances:
CO When the employee has cuts,
scratches,or other breaks in his or her
skin;
(it)When the employee judges that
hand contamination with blood may
occur,for example,when performing
phlebotomy on an uncooperative
source individual;and
(Hi)When the employee is receiving
training in phlebotomy.
(x)Masks,Eye Protection,and Face
Shields.Masks in combination with eye
protection devices,such as goggles or
glasses with solid side shields,or chin-
length face shields,shall be worn when
ever splashes,spray,spatter,or drop
lets of blood or other potentially infec
tious materials may be generated and
eye,nose,or mouth contamination can
be reasonably anticipated.
(xi)Gowns,Aprons,and Other Protec
tive Body Clothing.Appropriate protec
tive clothing such as,but not limited
to,gowns,aprons,lab coats,clinic
jackets,or similar outer garments
shall be worn in occupational exposure
situations.The type and characteris
tics will depend upon the task and de
gree of exposure anticipated.
(xii)Surgical caps or hoods and/or
shoe covers or boots shall be worn in
instances when gross contamination
can reasonably be anticipated (e.g.,au
topsies,orthopaedic surgery).
(4)Housekeeping—(i)General.Employ
ers shall ensure that the worksite is
maintained in a clean and sanitary
condition.The employer shall deter
mine and implement an appropriate
written schedule for cleaning and
method of decontamination based upon
the location within the facility,type of
surface to be cleaned,type of soil
present,and tasks or procedures being
performed in the area.
270
Exhibit A
Page 6 of 14
Occupational Safety and Health Admin.,Labor §1910.1030
(ii)All equipment and environmental
and working surfaces shall be cleaned
and decontaminated after contact with
blood or other potentially infectious
materials.
(A)Contaminated work surfaces shall
be decontaminated with an appropriate
disinfectant after completion of proce
dures;immediately or as soon as fea
sible when surfaces are overtly con
taminated or after any spill of blood or
other potentially infectious materials;
and at the end of the work shift if the
surface may have become contami
nated since the last cleaning.
(B)Protective coverings,such as
plastic wrap,aluminum foil,or imper
viously-backed absorbent paper used to
cover equipment and environmental
surfaces,shall be removed and replaced
as soon as feasible when they become
overtly contaminated or at the end of
the workshift if they may have become
contaminated during the shift.
(C)All bins,pails,cans,and similar
receptacles intended for reuse which
have a reasonable likelihood for be
coming contaminated with blood or
other potentially infectious materials
shall be inspected and decontaminated
on a regularly scheduled basis and
cleaned and decontaminated imme
diately or as soon as feasible upon visi
ble contamination.
(D)Broken glassware which may be
contaminated shall not be picked up
directly with the hands.It shall be
cleaned up using mechanical means,
such as a brush and dust pan,tongs,or
forceps.
(E)Reusable sharps that are con
taminated with blood or other poten
tially infectious materials shall not be
stored or processed in a manner that
requires employees to reach by hand
into the containers where these sharps
have been placed.
(iii)Regulated Waste—(A)Contami
nated Sharps Discarding and Contain
ment. (1)Contaminated sharps shall be
discarded immediately or as soon as
feasible in containers that are:
(t)Closable;
(ii)Puncture resistant;
(Hi)Leakproof on sides and bottom;
and
(iv)Labeled or color-coded in accord
ance with paragraph (g)(1) (i)of this
standard.
(2)During use,containers for con
taminated sharps shall be:
(/)Easily accessible to personnel and
located as close as is feasible to the im
mediate area where sharps are used or
can be reasonably anticipated to be
found (e.g.,laundries);
(ii)Maintained upright throughout
use;and
(iii)Replaced routinely and not be al
lowed to overfill.
(3)When moving containers of con
taminated sharps from the area of use,
the containers shall be:
(!)Closed immediately prior to re
moval or replacement to prevent spill
age or protrusion of contents during
handling,storage,transport,or ship
ping;
(ii)Placed in a secondary container if
leakage is possible.The second con
tainer shall be:
(A)Closable;
(B)Constructed to contain all con
tents and prevent leakage during han
dling,storage,transport,or shipping;
and
(Q Labeled or color-coded according
to paragraph (g)(l)(i)of this standard.
(4)Reusable containers shall not be
opened,emptied,or cleaned manually
or in any other manner which would
expose employees to the risk of
percutaneous injury.
(B)Other Regulated Waste Contain
ment—(1)Regulated waste shall be
placed in containers which are:
(/)Closable;
(ii)Constructed to contain all con
tents and prevent leakage of fluids dur
ing handling,storage,transport or
shipping;
(Hi)Labeled or color-coded in accord
ance with paragraph (g)(1) (i)this
standard;and
(iv)Closed prior to removal to pre
vent spillage or protrusion of contents
during handling,storage,transport,or
shipping.
(2)If outside contamination of the
regulated waste container occurs,it
shall be placed in a second container.
The second container shall be:
(i)Closable;
(it)Constructed to contain all con
tents and prevent leakage of fluids dur
ing handling,storage,transport or
shipping;
271
Exhibit A
Page 7 of 14
§1910.1030
(iii)Labeled or color-coded in accord
ance with paragraph (g)(1) (i)of this
standard;and
(iv)Closed prior to removal to pre
vent spillage or protrusion of contents
during handling,storage,transport,or
shipping.
(C)Disposal of all regulated waste
shall be in accordance with applicable
regulations of the United States,
States and Territories,and political
subdivisions of States and Territories.
(iv)Laundry.(A)Contaminated laun
dry shall be handled as little as pos
sible with a minimum of agitation.(/)
Contaminated laundry shall be bagged
or containerized at the location where
it was used and shall not be sorted or
rinsed in the location of use.
(2)Contaminated laundry shall be
placed and transported in bags or con
tainers labeled or color-coded in ac
cordance with paragraph (g)(1) (i)of
this standard.When a facility utilizes
Universal Precautions in the handling
of all soiled laundry,alternative label
ing or color-coding is sufficient if it
permits all employees to recognize the
containers as requiring compliance
with Universal Precautions.
(31 Whenever contaminated laundry
is wet and presents a reasonable likeli
hood of soak-through of or leakage
from the bag or container,the laundry
shall be placed and transported in bags
or containers which prevent soak-
through and/or leakage of fluids to the
exterior.
(B)The employer shall ensure that
employees who have contact with con
taminated laundry wear protective
gloves and other appropriate personal
protective equipment.
(C)When a facility ships contami
nated laundry off-site to a second facil
ity which does not utilize Universal
Precautions in the handling of all laun
dry,the facility generating the con
taminated laundry must place such
laundry in bags or containers which
are labeled or color-coded in accord
ance with paragraph (g)(1) (i).
(e)HIV and HBV Research Labora
tories and Production Facilities.(1)This
paragraph applies to research labora
tories and production facilities en
gaged in the culture,production,con
centration,experimentation,and ma
nipulation of HIV and HBV.It does not
29 CFR Ch.XVII (7-1-07 Edition)
apply to clinical or diagnostic labora
tories engaged solely in the analysis of
blood,tissues,or organs.These re
quirements apply in addition to the
other requirements of the standard.
(2)Research laboratories and produc
tion facilities shall meet the following
criteria:
(i)Standard microbiological practices.
All regulated waste shall either be in
cinerated or decontaminated by a
method such as autoclaving known to
effectively destroy bloodborne patho
gens.
(ii)Special practices.(A)Laboratory
doors shall be kept closed when work
involving HIV or HBV is in progress.
(B)Contaminated materials that are
to be decontaminated at a site away
from the work area shall be placed in a
durable,leakproof,labeled or color-
coded container that is closed before
being removed from the work area.
(C)Access to the work area shall be
limited to authorized persons.Written
policies and procedures shall be estab
lished whereby only persons who have
been advised of the potential bio-
hazard,who meet any specific entry re
quirements,and who comply with all
entry and exit procedures shall be al
lowed to enter the work areas and ani
mal rooms.
(D)When other potentially infectious
materials or infected animals are
present in the work area or contain
ment module,a hazard warning sign in
corporating the universal biohazard
symbol shall be posted on all access
doors.The hazard warning sign shall
comply with paragraph (g)(1) (ii)of this
standard.
(E)All activities involving other po
tentially infectious materials shall be
conducted in biological safety cabinets
or other physical-containment devices
within the containment module.No
work with these other potentially in
fectious materials shall be conducted
on the open bench.
(F)Laboratory coats,gowns,smocks,
uniforms,or other appropriate protec
tive clothing shall be used in the work
area and animal rooms.Protective
clothing shall not be worn outside of
the work area and shall be decontami
nated before being laundered.
272
Exhibit A
Page 8 of 14
Occupational Safety and Health Admin.,Labor §1910.1030
(G)Special care shall be taken to
avoid skin contact with other poten
tially infectious materials.Gloves
shall be worn when handling infected
animals and when making hand con
tact with other potentially infectious
materials is unavoidable.
(H)Before disposal all waste from
work areas and from animal rooms
shall either be incinerated or decon
taminated by a method such as
autoclaving known to effectively de
stroy bloodborne pathogens.
(I)Vacuum lines shall be protected
with liquid disinfectant traps and high-
efficiency particulate air (HEPA)fil
ters or filters of equivalent or superior
efficiency and which are checked rou
tinely and maintained or replaced as
necessary.
(J)Hypodermic needles and syringes
shall be used only for parenteral injec
tion and aspiration of fluids from lab
oratory animals and diaphragm bot
tles.Only needle-locking syringes or
disposable syringe-needle units (i.e.,
the needle is integral to the syringe)
shall be used for the injection or aspi
ration of other potentially infectious
materials.Extreme caution shall be
used when handling needles and sy
ringes.A needle shall not be bent,
sheared,replaced in the sheath or
guard,or removed from the syringe fol
lowing use.The needle and syringe
shall be promptly placed in a puncture-
resistant container and autoclaved or
decontaminated before reuse or dis
posal.
(K)All spills shall be immediately
contained and cleaned up by appro
priate professional staff or others prop
erly trained and equipped to work with
potentially concentrated infectious
materials.
(L) A spill or accident that results in
an exposure incident shall be imme
diately reported to the laboratory di
rector or other responsible person.
(M) A biosafety manual shall be pre
pared or adopted and periodically re
viewed and updated at least annually
or more often if necessary.Personnel
shall be advised of potential hazards,
shall be required to read instructions
on practices and procedures,and shall
be required to follow them.
(iii)Containment equipment.(A)Cer
tified biological safety cabinets (Class
I, II,or III)or other appropriate com
binations of personal protection or
physical containment devices,such as
special protective clothing,respirators,
centrifuge safety cups,sealed cen
trifuge rotors,and containment caging
for animals,shall be used for all activi
ties with other potentially infectious
materials that pose a threat of expo
sure to droplets,splashes,spills,or
aerosols.
(B)Biological safety cabinets shall
be certified when installed,whenever
they are moved and at least annually.
(3)HIV and HBV research labora
tories shall meet the following criteria:
(i)Each laboratory shall contain a
facility for hand washing and an eye
wash facility which is readily available
within the work area.
(ii)An autoclave for decontamina
tion of regulated waste shall be avail
able.
(4)HIV and HBV production facilities
shall meet the following criteria:
(i)The work areas shall be separated
from areas that are open to unre
stricted traffic flow within the build
ing.Passage through two sets of doors
shall be the basic requirement for
entry into the work area from access
corridors or other contiguous areas.
Physical separation of the high-con
tainment work area from access cor
ridors or other areas or activities may
also be provided by a double-doored
clothes-change room (showers may be
included),airlock,or other access fa
cility that requires passing through
two sets of doors before entering the
work area.
(ii)The surfaces of doors,walls,
floors and ceilings in the work area
shall be water resistant so that they
can be easily cleaned.Penetrations in
these surfaces shall be sealed or capa
ble of being sealed to facilitate decon
tamination.
(iii)Each work area shall contain a
sink for washing hands and a readily
available eye wash facility.The sink
shall be foot,elbow,or automatically
operated and shall be located near the
exit door of the work area.
(iv)Access doors to the work area or
containment module shall be self-clos
ing.
(v)An autoclave for decontamination
of regulated waste shall be available
273
Exhibit A
Page 9 of 14
§1910.1030
within or as near as possible to the
work area.
(vi)A ducted exhaust-air ventilation
system shall be provided.This system
shall create directional airflow that
draws air into the work area through
the entry area.The exhaust air shall
not be recirculated to any other area of
the building,shall be discharged to the
outside,and shall be dispersed away
from occupied areas and air intakes.
The proper direction of the airflow
shall be verified (i.e.,into the work
area).
(5)Training Requirements.Additional
training requirements for employees in
HIV and HBV research laboratories and
HIV and HBV production facilities are
specified in paragraph (g)(2)(ix).
(f)Hepatitis B vaccination and post-ex
posure evaluation and follow-up—(1)
General,(i)The employer shall make
available the hepatitis B vaccine and
vaccination series to all employees
who have occupational exposure,and
post-exposure evaluation and follow-up
to all employees who have had an expo
sure incident.
(ii)The employer shall ensure that
all medical evaluations and procedures
including the hepatitis B vaccine and
vaccination series and post-exposure
evaluation and follow-up,including
prophylaxis,are:
(A)Made available at no cost to the
employee;
(B)Made available to the employee
at a reasonable time and place;
(C)Performed by or under the super
vision of a licensed physician or by or
under the supervision of another li
censed healthcare professional;and
(D)Provided according to rec
ommendations of the U.S.Public
Health Service current at the time
these evaluations and procedures take
place,except as specified by this para
graph (f).
(iii)The employer shall ensure that
all laboratory tests are conducted by
an accredited laboratory at no cost to
the employee.
(2)Hepatitis B Vaccination,(i)Hepa
titis B vaccination shall be made avail
able after the employee has received
the training required in paragraph
(g)(2)(vii)(I)and within 10 working days
of initial assignment to all employees
who have occupational exposure unless
Exhibit A
Page 10 of 14
29 CFR Ch.XVII (7-1-07 Edition)
the employee has previously received
the complete hepatitis B vaccination
series,antibody testing has revealed
that the employee is immune,or the
vaccine is contraindicated for medical
reasons.
(ii)The employer shall not make par
ticipation in a prescreening program a
prerequisite for receiving hepatitis B
vaccination.
(iii)If the employee initially declines
hepatitis B vaccination but at a later
date while still covered under the
standard decides to accept the vaccina
tion,the employer shail make avail
able hepatitis B vaccination at that
time.
(iv)The employer shall assure that
employees who decline to accept hepa
titis B vaccination offered by the em
ployer sign the statement in appendix
A.
(v) If a routine booster dose(s)of hep
atitis B vaccine is recommended by the
U.S.Public Health Service at a future
date,such booster dose(s)shall be
made available in accordance with sec
tion (f)(1)(ii).
(3)Post-exposure Evaluation and Fol
low-up.Following a report of an expo
sure incident,the employer shall make
immediately available to the exposed
employee a confidential medical eval
uation and follow-up,including at least
the following elements:
(i)Documentation of the route(s)of
exposure,and the circumstances under
which the exposure incident occurred;
(ii)Identification and documentation
of the source individual,unless the em
ployer can establish that identification
is infeasible or prohibited by state or
local law;
(A)The source individual's blood
shall be tested as soon as feasible and
after consent is obtained in order to de
termine HBV and HIV infectivity.If
consent is not obtained,the employer
shall establish that legally required
consent cannot be obtained.When the
source individual's consent is not re
quired by law,the source individual's
blood,if available,shall be tested and
the results documented.
(B)When the source individual is al
ready known to be infected with HBV
or HIV,testing for the source individ
ual's known HBV or HIV status need
not be repeated.
274
Exhibit A
Page 11 of 14
Occupational Safety and Health Admin.,Labor §1910.1030
(C)Results of the source individual's
testing shall be made available to the
exposed employee,and the employee
shall be informed of applicable laws
and regulations concerning disclosure
of the identity and infectious status of
the source individual.
(iii)Collection and testing of blood
for HBV and HIV serological status;
(A)The exposed employee's blood
shall be collected as soon as feasible
and tested after consent is obtained.
(B)If the employee consents to base
line blood collection,but does not give
consent at that time for HIV serologic
testing,the sample shall be preserved
for at least 90 days.If,within 90 days of
the exposure incident,the employee
elects to have the baseline sample test
ed,such testing shall be done as soon
as feasible.
(iv)Post-exposure prophylaxis,when
medically indicated,as recommended
by the U.S.Public Health Service;
(v)Counseling;and
(vi)Evaluation of reported illnesses.
(4)Information Provided to the
Healthcare Professional,(i)The em
ployer shall ensure that the healthcare
professional responsible for the em
ployee's Hepatitis B vaccination is pro
vided a copy of this regulation.
(ii)The employer shall ensure that
the healthcare professional evaluating
an employee after an exposure incident
is provided the following information:
(A) A copy of this regulation;
(B) A description of the exposed em
ployee's duties as they relate to the ex
posure incident;
(C)Documentation of the route(s)of
exposure and circumstances under
which exposure occurred;
(D)Results of the source individual's
blood testing,if available;and
(E)All medical records relevant to
the appropriate treatment of the em
ployee including vaccination status
which are the employer's responsibility
to maintain.
(5)Healthcare Professional's Written
Opinion.The employer shall obtain and
provide the employee with a copy of
the evaluating healthcare profes
sional's written opinion within 15 days
of the completion of the evaluation.
(i)The healthcare professional's writ
ten opinion for Hepatitis B vaccination
shall be limited to whether Hepatitis B
vaccination is indicated for an em
ployee,and if the employee has re
ceived such vaccination.
(ii)The healthcare professional's
written opinion for post-exposure eval
uation and follow-up shall be limited to
the following information:
(A)That the employee has been in
formed of the results of the evaluation;
and
(B)That the employee has been told
about any medical conditions resulting
from exposure to blood or other poten
tially infectious materials which re
quire further evaluation or treatment,
(iii)All other findings or diagnoses
shall remain confidential and shall not
be included in the written report.
(6)Medical recordkeeping.Medical
records required by this standard shall
be maintained in accordance with para
graph (h)(1)of this section.
(g)Communication of hazards to em
ployees—(1)Labels and signs—(i)Labels.
(A)Warning labels shall be affixed to
containers of regulated waste,refrig
erators and freezers containing blood
or other potentially infectious mate
rial;and other containers used to
store,transport or ship blood or other
potentially infectious materials,ex
cept as provided in paragraph
(g)(1)(0(E).(F)and (G).
(B)Labels required by this section
shall include the following legend:
BIOHAZARD
(C)These labels shall be fluorescent
orange or orange-red or predominantly
so,with lettering and symbols in a con
trasting color.
(D)Labels shall be affixed as close as
feasible to the container by string,
wire,adhesive,or other method that
prevents their loss or unintentional re
moval.
275
§1910.1030
(E)Red bags or red containers may
be substituted for labels.
(F)Containers of blood,blood compo
nents,or blood products that are la
beled as to their contents and have
been released for transfusion or other
clinical use are exempted from the la
beling requirements of paragraph (g).
(G)Individual containers of blood or
other potentially infectious materials
that are placed in a labeled container
during storage,transport,shipment or
disposal are exempted from the label
ing requirement.
(H)Labels required for contaminated
equipment shall be in accordance with
this paragraph and shall also state
which portions of the equipment re
main contaminated.
(I)Regulated waste that has been de
contaminated need not be labeled or
color-coded.
(ii)Signs.(A)The employer shall post
signs at the entrance to work areas
specified in paragraph (e),HIV and
HBV Research Laboratory and Produc
tion Facilities,which shall bear the
following legend:
BIOHAZARD
(Name of the Infectious Agent)
(Special requirements for entering the area)
(Name,telephone number of the laboratory
director or other responsible person.)
(B)These signs shall be fluorescent
orange-red or predominantly so,with
lettering and symbols in a contrasting
color.
(2)Information and Training,(i)Em
ployers shall ensure that all employees
with occupational exposure participate
in a training program which must be
provided at no cost to the employee
and during working hours.
(ii)Training shall be provided as fol
lows:
(A)At the time of initial assignment
to tasks where occupational exposure
may take place;
Exhibit A
Page 12 of 14
29 CFR Ch.XVII (7-1-07 Edition)
(B)At least annually thereafter.
(iii)[Reserved]
(iv)Annual training for all employ
ees shall be provided within one year of
their previous training.
(v)Employers shall provide addi
tional training when changes such as
modification of tasks or procedures or
institution of new tasks or procedures
affect the employee's occupational ex
posure.The additional training may be
limited to addressing the new expo
sures created.
(vi)Material appropriate in content
and vocabulary to educational level,
literacy,and language of employees
shall be used.
(vii)The training program shall con
tain at a minimum the following ele
ments:
(A)An accessible copy of the regu
latory text of this standard and an ex
planation of its contents;
(B) A general explanation of the epi
demiology and symptoms of bloodborne
diseases;
(C)An explanation of the modes of
transmission of bloodborne pathogens;
(D)An explanation of the employer's
exposure control plan and the means
by which the employee can obtain a
copy of the written plan;
(E)An explanation of the appropriate
methods for recognizing tasks and
other activities that may involve expo
sure to blood and other potentially in
fectious materials;
(F)An explanation of the use and
limitations of methods that will pre
vent or reduce exposure including ap
propriate engineering controls,work
practices,and personal protective
equipment;
(G)Information on the types,proper
use,location,removal,handling,de
contamination and disposal of personal
protective equipment;
(H)An explanation of the basis for
selection of personal protective equip
ment;
(I)Information on the hepatitis B
vaccine,including information on its
efficacy,safety,method of administra
tion,the benefits of being vaccinated,
and that the vaccine and vaccination
will be offered free of charge;
(J)Information on the appropriate
actions to take and persons to contact
276
Exhibit A
Page 13 of 14
Occupational Safety and Health Admin.,Labor §1910.1030
in an emergency involving blood or
other potentially infectious materials;
(K)An explanation of the procedure
to follow if an exposure incident oc
curs,including the method of reporting
the incident and the medical follow-up
that will be made available;
(L)Information on the post-exposure
evaluation and follow-up that the em
ployer is required to provide for the
employee following an exposure inci
dent;
(M) An explanation of the signs and
labels and/or color coding required by
paragraph (g)(1);and
(N)An opportunity for interactive
questions and answers with the person
conducting the training session.
(viii)The person conducting the
training shall be knowledgeable in the
subject matter covered by the elements
contained in the training program as it
relates to the workplace that the train
ing will address.
(ix)Additional Initial Training for
Employees in HIV and HBV Labora
tories and Production Facilities.Em
ployees in HIV or HBV research labora
tories and HIV or HBV production fa
cilities shall receive the following ini
tial training in addition to the above
training requirements.
(A)The employer shall assure that
employees demonstrate proficiency in
standard microbiological practices and
techniques and in the practices and op
erations specific to the facility before
being allowed to work with HIV or
HBV.
(B)The employer shall assure that
employees have prior experience in the
handling of human pathogens or tissue
cultures before working with HIV or
HBV.
(C)The employer shall provide a
training program to employees who
have no prior experience in handling
human pathogens.Initial work activi
ties shall not include the handling of
infectious agents.A progression of
work activities shall be assigned as
techniques are learned and proficiency
is developed.The employer shall assure
that employees participate in work ac
tivities involving infectious agents
only after proficiency has been dem
onstrated.
(h)Recordkeeping—(1)Medical
Records,(i)The employer shall estab
lish and maintain an accurate record
for each employee with occupational
exposure,in accordance with 29 CFR
1910.1020.
(ii)This record shall include:
(A)The name and social security
number of the employee;
(B) A copy of the employee's hepa
titis B vaccination status including the
dates of all the hepatitis B vaccina
tions and any medical records relative
to the employee's ability to receive
vaccination as required by paragraph
(f)(2);
(C) A copy of all results of examina
tions,medical testing,and follow-up
procedures as required by paragraph
(f)(3);
(D)The employer's copy of the
healthcare professional's written opin
ion as required by paragraph (f)(5);and
(E) A copy of the information pro
vided to the healthcare professional as
required by paragraphs (f)(4)(ii)(B)(C)
and (D).
(iii)Confidentiality.The employer
shall ensure that employee medical
records required by paragraph (h)(1)
are:
(A)Kept confidential;and
(B)Not disclosed or reported without
the employee's express written consent
to any person within or outside the
workplace except as required by this
section or as may be required by law.
(iv)The employer shall maintain the
records required by paragraph (h)for at
least the duration of employment plus
30 years in accordance with 29 CFR
1910.1020.
(2)Training Records,(i)Training
records shall include the following in
formation:
(A)The dates of the training ses
sions;
(B)The contents or a summary of the
training sessions;
(C)The names and qualifications of
persons conducting the training;and
(D)The names and job titles of all
persons attending the training ses
sions.
(ii)Training records shall be main
tained for 3 years from the date on
which the training occurred.
(3)Availability,(i)The employer shall
ensure that all records required to be
maintained by this section shall be
277
§1910.1043
made available upon request to the As
sistant Secretary and the Director for
examination and copying.
(ii)Employee training records re
quired by this paragraph shall be pro
vided upon request for examination and
copying to employees,to employee rep
resentatives,to the Director,and to
the Assistant Secretary.
(iii)Employee medical records re
quired by this paragraph shall be pro
vided upon request for examination and
copying to the subject employee,to
anyone having written consent of the
subject employee,to the Director,and
to the Assistant Secretary in accord
ance with 29 CFR 1910.1020.
(4)Transfer of Records,(i)The em
ployer shall comply with the require
ments involving transfer of records set
forth in 29 CFR 1910.1020(h).
(ii)If the employer ceases to do busi
ness and there is no successor employer
to receive and retain the records for
the prescribed period,the employer
shall notify the Director,at least three
months prior to their disposal and
transmit them to the Director,if re
quired by the Director to do so,within
that three month period.
(i)Dares—(1)Effective Date.The
standard shall become effective on
March 6,1992.
(2)The Exposure Control Plan re
quired by paragraph (c)of this section
shall be completed on or before May 5,
1992.
(3)Paragraph (g)(2)Information and
Training and (h)Recordkeeping shall
take effect on or before June 4,1992.
(4)Paragraphs (d)(2)Engineering and
Work Practice Controls,(d)(3)Personal
Protective Equipment,(d)(4)House
keeping,(e)HIV and HBV Research
Laboratories and Production Facili
ties,(f)Hepatitis B Vaccination and
Post-Exposure Evaluation and Follow-
up,and (g) (1)Labels and Signs,shall
take effect July 6,1992.
(5)Sharps injury log.(i)The employer
shall establish and maintain a sharps
injury log for the recording of
percutaneous injuries from contami
nated sharps.The information in the
sharps injury log shall be recorded and
maintained in such manner as to pro
tect the confidentiality of the injured
employee.The sharps injury log shall
contain,at a minimum:
Exhibit A
Page 14 of 14
29 CFR Ch.XVII (7-1-07 Edition)
(A)The type and brand of device in
volved in the incident,
(B)The department or work area
where the exposure incident occurred,
and
(C)An explanation of how the inci
dent occurred.
(ii)The requirement to establish and
maintain a sharps injury log shall
apply to any employer who is required
to maintain a log of occupational inju
ries and illnesses under 29 CFR 1904.
(iii)The sharps injury log shall be
maintained for the period required by
29 CFR 1904.6.
APPENDIX A TO SECTION 1910.1030—HEPATITIS
B Vaccine Declination (Mandatory)
I understand that due to my occupational
exposure to blood or other potentially infec
tious 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 my
self.However,I decline hepatitis B vaccina
tion at this time.I understand that by de
clining 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 infec
tious materials and I want to be vaccinated
with hepatitis B vaccine,I can receive the
vaccination series at no charge to me.
[56 FR 64175,Dec.6, 1991,as amended at 57
FR 12717,Apr.13, 1992; 57 FR 29206,July 1,
1992;61 FR 5508,Feb.13.1996;66 FR 5325,Jan.
18, 2001: 71 FR 16672.16673,Apr.3,2006]
§1910.1043 Cotton dust.
(a)Scope and application.(1)This sec
tion,in its entirety,applies to the con
trol of employee exposure to cotton
dust in all workplaces where employees
engage in yarn manufacturing,engage
in slashing and weaving operations,or
work in waste houses for textile oper
ations.
(2)This section does not apply to the
handling or processing of woven or
knitted materials;to maritime oper
ations covered by 29 CFR Parts 1915
and 1918;to harvesting or ginning of
cotton;or to the construction industry.
(3)Only paragraphs (h)Medical sur
veillance,(k)(2)through (4)Record
keeping—Medical Records,and Appen
dices B, C and D of this section apply
in all work places where employees ex
posed to cotton dust engage in cotton
seed processing or waste processing op
erations.
278
Exhibit B
HEPATITIS B VACCINE DECLINATION
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 the expense of the
sponsoring COLLEGE department/program;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.
Print Name Job Title Department
Signature Date
***If I continue to have occupational exposure to blood and other potentially infectious
material,I understand that I have the option to receive the Hepatitis B vaccination series
at a later date,at the expense of the sponsoring COLLEGE department/program.
Exhibit C
Page 1 of3
FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM
CONTRACTOR CODE OF CONDUCT AND ETHICS
Fresno County is firmly committed to full compliance with all applicable laws,
regulations,rules and guidelines that apply to the provision and payment of mental health services.
Mental health contractors and the manner in which they conduct themselves are a vital part of this
commitment.
Fresno County has established this Contractor Code of Conduct and Ethics with which
contractor and its employees and subcontractors shall comply.Contractor shall require its employees
and subcontractors to attend a compliance training that will be provided by Fresno County.After
completion of this training,each contractor,contractor's employee and subcontractor must sign the
Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or
designee.
Contractor and its employees and subcontractor shall:
1.Comply with all applicable laws,regulations,rules or guidelines when providing and billing
for mental health services.
2.Conduct themselves honestly,fairly,courteously and with a high degree of integrity in their
professional dealing related to their contract with the County and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of the County.
3. Treat County employees,consumers,and other mental health contractors fairly and with
respect.
4.NOT engage in any activity in violation of the County's Compliance Program,nor engage in
any other conduct which violates any applicable law,regulation,rule or guideline
5. Take precautions to ensure that claims are prepared and submitted accurately,timely and are
consistent with all applicable laws,regulations,rules or guidelines.
6.Ensure that no false,fraudulent,inaccurate or fictitious claims for payment or reimbursement
of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented.Use billing codes that
accurately describe the services provided.
Exhibit C
Page 2 of 3
8. Act promptly to investigate and correct problems if errors in claims or billing are discovered.
9.Promptly report to the Compliance Officer any suspected violation(s)of this Code of Conduct
and Ethics by County employees or other mental health contractors,or report any activity that
they believe may violate the standards of the Compliance Program,or any other applicable
law,regulation,rule or guideline.Fresno County prohibits retaliation against any person
making a report.Any person engaging in any form of retaliation will be subject to disciplinary
or other appropriate action by the County.Contractor may report anonymously.
10.Consult with the Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law,regulation,rule or guideline.
11.Immediately notify the Compliance Officer if they become or may become an Ineligible person
and therefore excluded from participation in the Federal Health Care Programs.
Exhibit C
Page 3 of 3
Fresno County Mental Health Compliance Program
Contractor Acknowledgment and Agreement
I hereby acknowledge that I have received,read and understand the Contractor Code of Conduct and
Ethics.I herby acknowledge that I have received training and information on the Fresno County Mental
Health Compliance Program and understand the contents thereof.I further agree to abide by the
Contractor Code of Conduct and Ethics,and all Compliance Program requirements as they apply to my
responsibilities as a mental health contractor for Fresno County.
I understand and accept my responsibilities under this Agreement.I further understand that any
violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of
County policy and may also be a violation of applicable laws,regulations,rules or guidelines.I further
understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program
may result in termination of my agreement with Fresno County.I further understand that Fresno
County will report me to the appropriate Federal or State agency.
For Individual Providers
Name (print):
Discipline:•Psychiatrist •Psychologist •LCSW •LMFT
Signature :Date : / /
For Group or Organizational Providers
Group/Org. Name (print):
Employee Name (print):
Discipline:•Psychiatrist •Psychologist •LCSW •LMFT
•Other:
Job Title (if different from Discipline):
Signature:Date: / /
SELF-DEALING TRANSACTION DISCLOSURE FORM
Exhibit D
Page 1 of 2
In order to conduct business with the County of Fresno (hereinafter referred to as "County"),
members of a contractor's board of directors (hereinafter referred to as "County Contractor"),must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services,or both for the County.A self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation isa partyandin which one
ormore of its directors has a materialfinancial interest"
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member's name, job title (ifapplicable), and date this disclosure is being made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum,include a description of the following:
a. The name of the agency/company with which the corporation has the transaction;and
b. The nature of the material financial interest in the Corporation's transaction that the
board member has.
(4)Describe indetail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed bythe board member that is involved in the self-dealing transaction
described in Sections (3)and (4).
(1)Company Board Member Information:
Name:Date:
Job Title:
(2)Company/Agency Name and Address:
(3) Disclosure (Please describe the nature of the self-dealing transaction you are a party to)
Exhibit D
Page 2 of 2
(4)Explain whythis self-dealingtransaction isconsistent withthe requirements ofCorporationsCode5233(a)
(5)Authorized Signature
Signature:Date: