The Disease

Hepatitis B is a viral infection caused by the Hepatitis B virus (HBV) which causes death in 1-2% of those infected.  Most people with HBV recover completely, but approximately 5-10% become chronic carriers of the virus.  Most of these people have no symptoms, but can continue to transmit the disease to others.  Some may develop chronic active hepatitis and cirrhosis.  HBV may be a causative factor in the development of liver cancer.  Immunization against HBV can prevent acute hepatitis and its complications.

The Vaccine

The HBV vaccine is produced from yeast cells.  It has been extensively tested for safety and effectiveness in large scale clinical trials.

Approximately 90 percent of healthy people who receive two doses of the vaccine and a third dose as a booster achieve high levels of surface antibody (anti-HBs) and protection against the virus.  The HBV vaccine is recommended for workers with potential for contact with blood or body fluids.  Full immunization requires three doses of the vaccine over a six-month period, although some persons may not develop immunity even after three doses.

There is no evidence that the vaccine has ever caused Hepatitis B.  However, persons who have been infected with HBV prior to receiving the vaccine may go on to develop clinical hepatitis in spite of immunization.

Dosage and Administration

The vaccine is given in three intramuscular doses in the deltoid muscle.  Two initial doses are given one month apart and the third dose is given six months after the first.

Possible Vaccine Side Effects

The incidence of side effects is very low.  No serious side effects have been reported with the vaccine.  Ten to 20 percent of persons experience tenderness and redness at the site of injection and low grade fever.  Rash, nausea, joint pain, and mild fatigue have also been reported.  The possibility exists that other side effects may be identified with more extensive use.

 

CONSENT OF HEPATITIS B VACCINATION

I have knowledge of Hepatitis B and the Hepatitis B vaccination.  I have had an opportunity to ask questions of a qualified nurse or physician and understand the benefits and risks of Hepatitis B vaccination.  I understand that I must have three doses of the vaccine to obtain immunity.  However, as with all medical treatment, there is no guarantee that I will become immune or that I will not experience side effects from the vaccine.  I give my consent to be vaccinated for Hepatitis B.

 

_____________________________________________________________     _______________________________________
Signature of Employee (consent for Hepatitis B vaccination)                                             Date

 

_____________________________________________________________     _______________________________________
Signature of Witness                                                                                                                            Date

 

 

REFUSAL OF HEPATITIS B VACCINATION

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

 

_____________________________________________________________     _______________________________________
Signature of Employee (refusal for Hepatitis B vaccination)                                               Date

 

_____________________________________________________________     _______________________________________
Signature of Witness                                                                                                                            Date

 

I refuse because I believe I have (check one)

                       started the series                                             completed the series

            _____ other, please describe:  _____________________________________________________

 

 

RELEASE FOR HEPATITIS B MEDICAL INFORMATION

 

I hereby authorize _____________________________________________________________________
                                         (name and address of individual or organization holding Hepatitis B records)

to release to the Independence Community School District my Hepatitis B vaccination records for required

employee records. 

I hereby authorize release of my Hepatitis B status to a health care provider in the event of an exposure incident.

 

_____________________________________________________________     _______________________________________
Signature of Employee                                                                                                                      Date

 

_____________________________________________________________     _______________________________________
Signature of Witness                                                                                                                          Date

 

CONFIDENTIAL RECORD

 

_____________________________________________________________     _______________________________________
Employee Name (last, first, middle)                                                                                              DOB

Job Title:  _____________________________________________________________     

     Hepatitis B Vaccination Date           Lot Number                 Site                       Administered By
1  ________________________         ____________          ___________         _____________________________________
2  ________________________         ____________          ___________         _____________________________________
3  ________________________         ____________          ___________         _____________________________________

Additional Hepatitis B status information:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
 

_____________________________________________________________     _______________________________________
Provider Signature                                                                                                                            Date

 

 

CONFIDENTIAL RECORD

_____________________________________________________________     _______________________________________
Employee Name (last, first, middle)                                                                                              DOB

Job Title:  _____________________________________________________________     

Post-exposure incident:  (Date, time, circumstances, route under which exposure occurred)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
 

Identification and documentation of source individual:
____________________________________________________________________________________________________

Source blood testing consent:
____________________________________________________________________________________________________

Description of employee's duties as related to the exposure incident:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Copy of information provided to health care professional evaluating an employee after an exposure incident:
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Attach a copy of all results of examinations, medical testing, follow-up procedures, and health care professional's written opinion.
____________________________________________________________________________________________________

Comments/Plan
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
 

_____________________________________________________________     _______________________________________
Provider Signature                                                                                                                               Date

 

Universal precautions (UP) are intended to prevent transmission of infection, as well as decrease the risk of exposure for employees and students.  It is not currently possible to identify all infected individuals, thus precautions must be used with every individual.  UP pertain to blood and other potentially infectious materials (OPIM) containing blood.  These precautions do not apply to other body fluids and wastes (OBFW) such as saliva, sputum, feces, tears, nasal secretions, vomitus and urine unless blood is visible in the material.  However, these OBFW can be sources of other infections and should be handled as if they are infectious.  The single most important step in preventing exposure to and transmission of any infection is anticipating potential contact with infectious materials in routine as well as emergency situations.  Based on the type of possible contact, employees and students should be prepared to use the appropriate precautions prior to the contact.  Diligent and proper hand washing, the use of barriers, appropriate disposal of waste products and needles, and proper decontamination of spills are essential techniques of infection control.  All individuals should respond to situations practicing UP followed by the activation of the school response team plan.  Using common sense in the application of these measures will enhance protection of employees and students.

Hand Washing

Proper hand washing is crucial to preventing the spread of infection.  Textured jewelry on the hands or wrists should be removed prior to washing and kept off until completion of the procedure and the hands are rewashed.  Use of running water, lathering with soap and using friction to clean all hand surfaces is key.  Rinse well with running water and dry hands with paper towels.

• Hands should be washed before physical contact with individuals and after contact is completed.
• Hands should be washed after contact with any used equipment.
• If hands (or other skin) come into contact with blood or body fluids, hands should be washed immediately before touching anything else.
• Hands should be washed whether gloves are worn or not and, if gloves are worn, after the gloves are removed.

Barriers

Barriers anticipated to be used at school include disposable gloves, absorbent materials and resuscitation devices.  Their use is intended to reduce the risk of contact with blood and body fluids as well as to control the spread of infectious agents from individual to individual.  Gloves should be worn when in contact with blood, OPIM or OBFW.  Gloves should be removed without touching the outside and disposed of after each use.

Disposal of Waste

Blood, OPIM, OBFW, used gloves, barriers and absorbent materials should be placed in a plastic bag and disposed of in the usual procedure.  When the blood or OPIM is liquid, semi-liquid or caked with dried blood, it is not absorbed in materials, and is capable of releasing the substance if compressed, special disposal as regulated waste is required.  A band-aid, towel, sanitary napkin or other absorbed waste that does not have the potential of releasing the waste if compressed would not be considered regulated waste.  It is anticipated schools would only have regulated waste in the case of a severe incident.  Needles, syringes and other sharp disposable objects should be placed in special puncture-proof containers and disposed of as regulated waste.  Bodily wastes such as urine, vomitus or feces should be disposed of in the sanitary sewer system.

Clean up

Spills of blood and OPIM should be cleaned up immediately.  The employee should:

• Wear gloves.
• Clean up the spill with paper towels or other absorbent material.
• Use a solution of one part household bleach to one hundred parts of water (1:100) or other EPA-approved disinfectant and use it to wash the area well.
• Dispose of gloves, soiled towels and other waste in a plastic bag.
• Clean and disinfect reusable supplies and equipment.

Laundry

Laundry with blood or OPIM should be handled as little as possible with a minimum of agitation.  It should be bagged at the location.  If it has the potential of releasing the substance when compacted, regulated waste guidelines should be followed.  Employees who have contact with this laundry should wear protective barriers.

Exposure

An exposure to blood or OPIM through contact with broken skin, mucous membrane or by needle or sharp stick requires immediate washing, reporting and follow-up.

• Always wash the exposed area immediately with soap and water.
• If a mucous membrane splash (eye or mouth) or exposure of broken skin occurs, irrigate or wash the area thoroughly.
• If a cut or needle stick injury occurs, wash the area thoroughly with soap and water.

The exposure should be reported immediately, the parent or guardian is notified, and the person exposed contacts a physician for further health care.

 

EMPLOYEES ARE HEREBY NOTIFIED it is a violation of the Substance-Free Workplace policy for an employee to unlawfully manufacture, distribute, dispense, possess, use, or be under the influence of in the workplace any narcotic drug, hallucinogenic drug, amphetamine, barbiturate, marijuana or any other controlled substance or alcohol, as defined in Schedules I through V of section 202 of the Controlled Substances Act (21 U.S.C. 812) and as further defined by regulation at 21 C.F.R. 1300.11 through 1300.15 and Iowa Code Chapter 204.

"Workplace" is defined as the site for the performance of work done in the capacity as an employee.  This includes school district facilities, other school premises or school district vehicles.  Workplace also includes nonschool property if the employee is at any school-sponsored, school-approved or school-related activity, event or function, such as field trips or athletic events where students are under the control of the school district or where the employee is engaged in school business.

The superintendent retains the discretion to discipline an employee for violation of the Substance-Free Workplace policy.  If the employee fails to successfully participate in such a program, the employee may be subject to discipline up to and including termination.

EMPLOYEES ARE FURTHER NOTIFIED it is a condition of their continued employment that they comply with the above policy of the school district and will notify their supervisor of their conviction of any criminal drug statute for a violation committed in the workplace, no later than five days after the conviction.

 

SUBSTANCE-FREE WORKPLACE ACKNOWLEDGMENT FORM

I, ____________________________________, have read and understand the Substance-Free Workplace policy.  I understand that if I violate the Substance-Free Workplace policy, I may be subject to discipline up to and including termination.  If I fail to successfully participate in a substance abuse treatment program, I understand I may be subject to discipline up to and including termination.  I understand that if I am required to participate in a substance abuse treatment program and I refuse to participate, I may be subject to discipline up to and including termination.  I also understand that if I am convicted of a criminal drug offense committed in the workplace, I must report that conviction to my supervisor within five days of the conviction.

 

_______________________________________________________________________     _____________________________________
(Signature of Employee)                                                                                                                                            (Date)

 

A superintendent who suspects an employee has a substance abuse problem will follow these procedures:

         1.      Identification - the superintendent will document the evidence the superintendent has which leads the superintendent to conclude the employee has violated the Substance-Free Workplace policy.  After the superintendent has determined there has been a violation of the Substance-Free Workplace policy, the superintendent will discuss the problem with the employee.  The superintendent will also contact Law Enforcement and ask that they do an investigation into this incident.

         2.      Discipline - if, after the discussion with the employee, the superintendent determines there has been a violation of the Substance-Free Workplace policy, the superintendent may recommend discipline up to and including termination.  Participation in a substance abuse treatment program is voluntary.

         3.      Conviction - if an employee is convicted of a criminal drug offense committed in the workplace, the employee must notify the employer of the conviction within five days of the conviction.

 

EMPLOYEES GOVERNED BY THE DRUG AND ALCOHOL TESTING POLICY ARE HEREBY NOTIFIED they are subject to the school district's drug and alcohol testing program for pre-employment drug testing and random, reasonable suspicion and post-accident drug and alcohol testing as outlined in the Drug and Alcohol Testing Program policy, its supporting documents and the law.

Employees who operate school vehicles classified as “commercial motor vehicles” by the U.S. Department of Transportation are subject to drug and alcohol testing.  A “commercial motor vehicle” is a vehicle that transports sixteen or more persons including the driver or has a gross vehicle weight rating (GVWR) of 26,001 pounds or more.  For purposes of the drug and alcohol testing program, “employees” also includes applicants who have been offered a position to operate a commercial motor vehicle owned by the school.  Employees that will operate a school-owned commercial motor vehicle are subject to the drug and alcohol testing program regulations beginning the first day they are offered a position to operate a school vehicle and continue to be subject to the drug and alcohol testing program until such time employment is terminated or the employee will no longer operate, at any time, a commercial motor vehicle for the school.

It is the responsibility of the superintendent to inform employees of the drug and alcohol testing program requirements.  Employees with questions regarding the drug and alcohol testing requirements will contact the transportation director, 1812 Mustang Way Dr (319) 334-7435 and/or school nurse, 1103 1^st Street West            (319) 334-7425, Independence, IA 50644.

EMPLOYEES GOVERNED BY THE DRUG AND ALCOHOL TESTING POLICY ARE FURTHER NOTIFIED that employees violating this policy, its supporting documents or regulations will be subject to discipline up to and including termination.

EMPLOYEES GOVERNED BY THE DRUG AND ALCOHOL TESTING POLICY ARE FURTHER NOTIFIED that information related to drug or alcohol violations will be reported to the Federal Motor Carrier Safety Administration (FMCSA) Clearinghouse.

EMPLOYEES GOVERNED BY THE DRUG AND ALCOHOL TESTING POLICY ARE FURTHER NOTIFIED it is a condition of their continued employment to comply with the Drug and Alcohol Testing Program policy, its supporting documents, regulations and the law.  It is a condition of continued employment for employees operating a school vehicle to notify their supervisor of any prescription medication they are using.  Drug and alcohol testing records about a driver are confidential and are released in accordance with this policy, its supporting documents, regulations or the law.

 

I, ______________________________________________________________ am currently employed by
                                               Name of Undersigned

 __________________________________________________________ who participates in the Drug and Alcohol
                                          Employer   

Program through ____________________________________________.  I consent to have my records pertaining                                                                                                              
                                       Drug & Alcohol Testing Provider

to drug and alcohol testing released to the Independence Community School District for the past 24 months of

employment.

_______________________________________________         _______________
(Signature)                                                                                                            (Date)

_______________________________________________         _______________
(Signature of Employer)                                                                                   (Date)

 

_________________________________________________         ______________________________________
                                 Name                                                                                     Social Security Number

 

I certify that I have been employed by the following employers during the two years prior to the date stated below and that I was required to possess a commercial driver’s license (CDL) and submit to drug and alcohol testing during the term of my employment.

 

Company  _____________________________________________________________________

Address  ______________________________________________________________________

City/State/Zip  _________________________________________________________________

 

Company  _____________________________________________________________________

Address  ______________________________________________________________________

City/State/Zip  _________________________________________________________________

 

Company  _____________________________________________________________________

Address  ______________________________________________________________________

City/State/Zip  _________________________________________________________________

 

I hereby release my records pertaining to my driving and drug and alcohol testing results.

 

_________________________________________________     ______________________________
(Signature)                                                                                                              (Date)

 

I, ( ______________________________________________________ ), have received a copy, read and
                                         Name of Employee

understand the Drug and Alcohol Testing Program policy and its supporting documents.  I have also read and

understand the “Drug and Alcohol Training Handbook” provided to me by the district.  I consent to submit to the

drug and alcohol testing program as required by the Drug and Alcohol Testing Program policy, its supporting

documents, regulations and the law.

I understand that if I violate the Drug and Alcohol Testing Program policy, its supporting documents, regulations

or the law, I may be subject to discipline up to and including termination.

I also understand that I must inform my supervisor of any prescription medication I use when requested.  I further

understand that drug and alcohol testing records about me are confidential and may be released in accordance with

this policy, its supporting documents, regulations or the law.

 

_______________________________________________     _____________________________
(Signature of Employee)                                                                                      (Date)

_______________________________________________     _____________________________
(Witness/Transportation Director)                                                                       (Date)

 

I, (   Name of Employee___   ), understand that as part of my employment in a position that requires a commercial driver’s license in the Independence Community School District, I grant consent for the District to conduct queries of the Federal Motor Carrier Safety Administration (“FMCSA”) Commercial Driver’s License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse.  I further consent to the District sharing information related to my drug and alcohol testing results with prior, current and future employers, as well as the FMCSA Clearinghouse in accordance with state and federal laws. 

I understand that the District will check and perform queries of my drug and alcohol testing results prior to my employment in any position which requires the use of a commercial driver’s license.  I further understand the District will check and perform queries of my testing results annually and is required to report any drug and alcohol violations of this policy to the FMCSA Clearinghouse. 

I understand that I am not required to consent to the query of the FMCSA Clearinghouse or the District sharing of drug and alcohol testing information with past, present or future employers or the FMCSA Clearinghouse; but that without my consent I understand I will be prohibited from performing safety sensitive functions, including driving a commercial motor vehicle, as required by FMCSA’s drug and alcohol program regulations. 

I hereby give my consent to the District to perform queries of the FMCSA Clearinghouse and share my drug and alcohol testing results with past, present and future employers, as well as the FMCSA Clearinghouse.

 

__________________________________________________               ________________________
(Signature of Employee)                                                                                      (Date)

 

PRE-EMPLOYMENT PROCEDURES FOR BUS DRIVERS

All advertisements must include a statement that explains the position of a driver in the Independence Community School District is subject to drug and alcohol testing to include pre-employment testing.  Should the potential employee already be under a recognized or approved Department of Transportation (D.O.T.) testing program, the pre-employment testing may be waived at the discretion of the superintendent/designee.  The potential employee must provide proof of participation in such a program (403.7E2).  A potential employee that is not currently under another approved testing program must consent to release any and all drug and alcohol related information records (403.7E3) from any previous employer dating back 24 months as well as be subject to pre-employment testing.

All potential drivers will be given training on controlled substances and alcohol use by the transportation director prior to being eligible for driving duties.  This training will consist of a self study of the “Drug and Alcohol Training Handbook” developed by the D.O.T.  Upon completion of this self study, the potential employee will sign off on the Drug and Alcohol Acknowledgement Form (403.7E4) in the presence of the transportation director that they have read and understand the contents of the handbook.  The transportation director will receive all acknowledgement forms and maintain a confidential file on the drug and alcohol testing program for each employee under this program.  Records will be maintained for a minimum of five years.

The transportation director will coordinate all testing with an approved D.O.T. provider.  Should a potential employee test positive or they have refused to any part of the above, mentioned procedures, they will not be considered for employment.

 

EMPLOYMENT PROCEDURES FOR BUS DRIVERS

All bus drivers are subject to random testing at any time throughout the calendar year.  Quarterly random testing will be done.  Should a bus driver be involved in an accident while operating a school vehicle (CMV), the school district will test each surviving driver for alcohol and controlled substances when either:

• The accident involved a FATALITY; or
• The driver RECEIVED A CITATION under state or local law for a moving traffic violation arising from the accident, and either ONE or BOTH of the following OCCURRED in the accident:

1. 1. Bodily injury requiring immediate medical treatment away from the scene.
   2. One or more of the motor vehicles incurred disabling damage requiring it to be towed from the scene by another motor vehicle or tow truck.

 

REASONABLE SUSPICION

Should a bus driver’s behavior be questioned as potentially being under the influence, it is recommended that there be two witnesses to the behavior, but it is not required.  When considering reasonable suspicion, only the transportation director/designee is authorized to request the test be administered. It is important to note that only those who have received the U.S. D.O.T. training may request this test.  A driver can be notified for a reasonable suspicion test only just before, during, or just after performing a safety sensitive function (within 30 minutes).  When it is believed reasonable suspicion exists, it is important to meet with the driver in private and document the observations leading to the reasonable suspicion test (403.7E5).  Upon completion of the meeting, the transportation director may notify the program provider for a test to be administered.  Failure by the employee to submit to the test will be considered grounds for termination with the Independence Community School District.