SAFETY MANUAL

Academic Year 2021-2022

SAFETY MANUAL TABLE OF CONTENTS

Section 1 Environment of Care Management Plan Evacuation Route Map Section 2 Hazardous Materials & Waste Management Plan Section 3 Hazard Communication Program Section 4 Chemical Inventory Section 5 Bloodborne Pathogen Exposure Control Plan Section 6 Tuberculosis Plan Section 7 Security Management Plan Section 8 Bomb Threat Plan Section 9 Electrical Outage Plan Section 10 Fire Safety Management Plan Section 11 Fire Response Plan Section 12 Weapons Control Plan Section 13 Tornado Plan Section 14 Return to F2F Classes – Safer Return Protocols Section 15 Safety Training Components of Training Safety Contacts Safety/Annual Updates for Students and Faculty Log – Review of Safety Manual Master Copies of Quizzes, Questionnaires

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE Environment of Care Management Plan

Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC

PURPOSE:

The purpose of the Environment of Care Management Plan is to define how a physical environment free of recognized hazards and managed activities may reduce the risk of injuries and to protect faculty, students, patients and visitors in the environment of care.

SCOPE:

The scope of the Environment of Care Management Plan, consisting of: Safety and Security, Hazardous Materials and Wastes, Fire Safety, Utilities and Other Physical Environment Requirements, and applies to all faculty, students, volunteers, and contract personnel that are working at CCMLS. The plan specifically excludes activities or responsibilities in any private physician practice or retail business located in the medical office buildings on the Medical Center of Aurora North campus. The plan is applied to 730 Potomac Street, Suite 102, Aurora, CO 80011. The plan also applies to all ongoing construction, remodel or department adjustments or modifications that may be completed.

FUNDAMENTALS:

A. CCMLS Faculty need appropriate information and training to develop an understanding of safe working conditions and safe work practices within their area of responsibility.

B. Safe working conditions and practices are established by using knowledge of safety principles to

educate faculty/students, design appropriate work environments, purchase appropriate equipment and supplies, and monitor the implementation of the processes and policies.

C. Safety is dynamic. Regular evaluation of the environment for work practices and hazards is

required to maintain a current relevant safety program. The program should change as needed to respond to identified risks, hazards and regulatory compliance issues.

RESPONSIBILITIES: A. The CCMLS Program Director and faculty are authorized to take immediate and appropriate

action in the event of an emergency situation where there is a clear and present danger that poses a threat to life, a threat of personal injury, or a threat of damage to property.

B. The CCMLS Program Director and faculty are responsible for orienting new faculty/students to the department and, as appropriate, to job and task specific safety procedures, and for investigation of incidents.

C. Individual faculty/students are responsible for learning and following job, and task-specific, procedures for safe operations.

ELEMENTS OF ENVIRONMENT OF CARE MANAGEMENT PLAN: Safety and Security, Hazardous Materials and Wastes, Fire Safety, Medical Equipment, Utilities and Other Physical Environment Requirements

PROCESSES OF SAFETY

Safety Inspections The goal of performing safety inspections is to reduce the likelihood of future incidents or other

negative experiences that have the potential to result in an injury, an accident, or other loss to faculty, students, visitors or CCMLS assets.

A. The City of Aurora inspected the facility prior to occupancy and agreed that the space was

fit for occupancy. The MOB Management company (CBRE) conducts monthly property inspections of the facility.

B. CCMLS maintains safety policies and procedures that are evaluated annually or as new procedures or needs arise.

C. The results of the safety inspection process are used to: • Create new or revised safety policies and procedures, • Identify new environmental items for the areas affected, • Improve safety orientation and education programs, and • Help define safety performance monitoring, and indicators.

Smoking Policy CCMLS maintains a non-smoking campus and has developed and maintains a policy prohibiting smoking in all areas of all buildings and areas of buildings and grounds where CCMLS is located. Medical Emergencies Should a medical emergency develop which requires immediate intervention by trained personnel, proceed as follows:

• Call 911; reassure the injured person that help is on the way; remain calm and provide the following information:

1. nature of medical emergency 2. building name and address 3. exact location and name of sick or injured person

• Call the MOB Management Office (303-360-3178), and provide the following information:

1. your name and company name 2. nature of medical emergency 3. exact location and name of sick or injured person 4. whether or not you have called for trained assistance 5. a number where you can be located

• Direct any on-lookers from the area of the injured person; clear the area of any objects that might impede the rescue or interfere with emergency personnel

• Remain with the injured person; DO NOT move the injured person unless there is immediate danger of further injury; keep the injured person warm and comfortable

• Designate a responsible person to: 1. wait at the building’s main entrance for medical personnel; when they

arrive, direct them to the injured person 2. whenever possible, have an elevator standing for the rescue team as

necessary

PROCESSES OF SECURITY CCMLS has developed procedures describing the processes it implements to effectively manage the security of faculty, students, and visitors. Procedures are evaluated annually, and modified as necessary, based on changes in conditions, regulations and standards, and identified needs. CCMLS is responsible for providing faculty and students with an orientation to applicable security procedures. Identification Processes CCMLS has determined that identification name badges must be provided for and worn by all students. Visitors to CCMLS will be under the supervision of faculty. Faculty and students are expected to report suspicious activity or individuals to the MOB management office (303-360-3178; after hours – 303-870-4005), and/or call “911” as appropriate. Security Sensitive Areas CCMLS has designated the entire Center facility as a “security sensitive area”. Access to the area will be restricted and monitored through controls such as identification badges, faculty supervision, restricted keys, special lock systems, visual identification, etc.

CCMLS also has policies related to security response for the following: • Bomb Threat • Fire Alarm or Fire Incident • Weapons Control

PROCESSES FOR HAZARDOUS MATERIALS MANAGEMENT AND STORAGE

CCMLS has processes to effectively manage hazardous materials and waste. The plan includes processes to protect the facility, faculty, students, and visitors from these materials and minimize the risk of harm and impact from exposure. The processes include education, procedures for safe use, storage and disposal, and management of spills or exposures. This program is evaluated annually, changed as necessary, based on risk assessment of the environment, changes in conditions, regulations and standards, and identified needs.

CCMLS maintains an inventory of the hazardous materials and wastes it manages. The

department leadership assures the safe selection, storage, handling, use, and disposal of hazardous materials. The department is responsible for evaluating Material Safety Data Sheets for hazards before purchase of departmental supplies to assure they are appropriate, and chooses the least hazardous practical alternative.

CCMLS has established and maintains processes for identifying, selecting, handling, storing, transporting, using, and disposing of hazardous materials and waste from receipt or generation through use and/or final disposal, including managing the following:

• Chemicals: Chemical materials are identified and ordered by faculty. Appropriate storage space is maintained by CCMLS, and reviewed as part of safety inspections. Chemical materials are maintained in labeled containers, and faculty/students are trained in understanding MSDS information, and in the appropriate and safe handling of the chemicals they use.

Chemical waste is held in a designated area, until arrival of the licensed contractor. The contractor lab packs the chemicals, completes the manifests, and removes the packaged waste. A disposal copy of the manifest is returned to verify legal disposal of the waste.

• Infectious and regulated medical wastes, including sharps: These materials are

found in the student laboratory area. The program is designed to identify, separate, collect, and control potentially bio-hazardous materials, and to collect them for licensed disposal. Faculty/students are trained about handling materials in the regulated medical

wastes program. Labeled and specialized containers are used to collect and transport these wastes, and all waste removal is manifested by the licensed contractor.

CCMLS has a spill procedure that evaluates spills to determine if outside assistance is

necessary. A minor (incidental) spill that can be cleaned up by the faculty/students involved with their training and personal equipment does not require additional response.

A spill that exceeds the capability of the faculty/students to neutralize and clean up requires a response from outside the facility. In these cases, the area is evacuated, ventilation controlled, and the Aurora Fire Department is called (911). The Fire Department takes control of the site and cleanup, or arrange for it to be cleaned up. Once determined safe, faculty/students finish the cleanup and recovery. Faculty/students, are trained to recognize the potential for a spill that is not safe to handle, and how to contact the Aurora Fire Department. Faculty/students are cautioned to err on the side of safety, and not to handle chemical spills that exceed their training, or the personal protection they have available.

Manifests Each load of hazardous waste removed from the facility is documented by a manifest, as mandated by federal or state agencies. The manifests have multiple copies, and one is left at the time the hazardous wastes are removed. Another copy travels with the waste, and is returned to CCMLS once the wastes have been legally disposed of, to document the completion of the activity. These copies are matched, to assure that no load has been lost or misplaced, and kept for the record. These copies are maintained by CCMLS. If a completed copy of the manifest is not returned within the deadline established by law and regulation, the appropriate governmental agency is notified.

Waste Labeling All hazardous wastes are labeled from generation to removal. Some wastes, such as bio-hazardous wastes are labeled by placement in a red bag; other wastes are labeled with specific signs or with text labels.

Bio-hazardous Waste: These are placed in red bags, then placed in plastic bins with external labeling as bio-hazardous wastes, or in a labeled roll-away container provided by the vendor, also labeled with the OSHA Bio-hazardous labeling and required placarding. The red bags are deemed to be labeled, as these bags are not used for any other purpose, and any material in a red bag is treated as bio-hazardous. Chemical Materials and Waste: Chemical materials are labeled throughout their use and handling at CCMLS. The label is on the container prior to receipt, or is placed on containers filled or mixed at CCMLS. Chemical wastes are labeled on the containers, and handled in accordance with licensed contractor disposal procedures.

Separation of Waste Handling Areas CCMLS maintains appropriate handling and storage areas for hazardous wastes that are

separated and maintained to minimize the possibility of contamination of food, clean and sterile goods, or contact with faculty, students or visitors.

Hazardous wastes are moved in covered or closed containers, from holding areas to the storage space designated for processing and handling those wastes

Routing of materials during transport is determined to minimize contact with visitors, and to protect faculty/students and the facility from contamination. Where food, clean and sterile materials, and faculty/students are moved on the same transportation vehicle as wastes (e. g., elevators), scheduling and other practices minimize the potential for cross contamination.

PROCESSES OF FIRE SAFETY CCMLS has processes to effectively manage the fire safety environment of faculty, students and visitors. The program is evaluated annually, and modified as necessary, based on changes in conditions, regulations and standards, and identified needs.

Protecting Faculty, Students and Visitors The MOB Management Company (CBRE) is responsible for managing the program for protecting faculty, students, visitors, and property from fire, smoke, and products of combustion. The fire safety program includes three phases: 1. The first is design of buildings and spaces to assure compliance with current local, state, and

national building and fire codes. CBRE contracts with qualified architects and engineers to develop building designs. All designs are reviewed by local or state agencies (City of Aurora) as a part of the construction and permitting process. A vigorous construction monitoring and building commissioning program round out the design phase.

2. The second phase is maintenance of the current building. The standards are applied through a process of planned maintenance and management of the work done by contractors to ensure the end product of all work meets code requirements.

3. The third phase is an active program of fire prevention, fire safety, and fire response training.

Fire Detection and Response System Tests and Inspections CBRE is responsible for maintenance of the Fire/Life Safety System, including:

• Fire Alarm Pull Stations • Smoke Detection System • Emergency Stairways • Elevator Recall • Audio/Visual Alarms

Fire Response Plan The Fire Response Plan provides clear, specific instructions for faculty/students responding to an emergency. The procedures provide information about notifying appropriate individuals of the emergency and actions to take to protect faculty/student/visitor safety. CCMLS is responsible for maintaining copies of emergency procedures in a continuously accessible location. CCMLS is responsible for developing and training faculty/students about department specific emergency fire response procedures. Fire Plan Elements • The roles of all faculty/students at and near the point of fire origin are defined. The basic plan

in CCMLS is based on the acronym “RACE”: Rescue - anyone directly affected by the fire Alarm - by pulling fire alarm pull stations, and calling 911 on the phones Contain - close doors to contain smoke and the products of combustion Extinguish – or if cannot extinguish safely Evacuate

(attempt to extinguish or prepare to relocate patients) • The roles of all faculty/students away from the point of fire origin are to close doors, evaluate

the situation, and assist as appropriate Processes to Control Flammability of New Acquisitions The general contractor and architect is responsible for assuring fire rated products installed during construction projects meet code standards. Fire-rated products are identified for each

project using standard specifications. CBRE maintains documentation on products installed during each project (in the MOB office).

Fire Alarm Tests Fire alarm tests are an important tool to maintain the readiness of staff to respond to a fire

emergency. The MOB conducts, and building occupants are requested to participate in annual fire alarm tests.

Maintaining fire-safety equipment and building features

Fire Alarm and Related Systems 1. CBRE is responsible for maintenance of the fire alarm and related systems. 2. Carbon dioxide and other gaseous automatic fire-extinguishing systems are tested for proper

operation at least annually by a licensed contractor/vendor. 3. Each portable fire extinguisher is clearly identified, and maintained at least annually by a

licensed contractor/vendor. 4. Activity of the licensed contractor/vendor is generally limited to troubleshooting and minor

repair. Competent contractors are used to test, inspect, maintain and repair systems where needed, to assure the special skills and equipment they have are available. Documentation is maintained as part of the CBRE database, to assure testing is done in a timely fashion, and to document results.

PROCESSES OF SCHOOL EQUIPMENT

CCMLS has processes to manage the effective, safe and reliable operation of school equipment. This program evaluated, and changed as necessary, based on changes in conditions, regulations and standards, and identified needs

Selection and Acquisition CCMLS has overall responsibility for coordinating the school equipment selection and acquisition process.

Inspection, Testing and Maintenance – School Equipment The frequency of planned maintenance is determined based on manufacturer recommendations, accreditation or regulatory requirements, and local operating experience. Wherever possible, maintenance/repair of equipment is done by the Biomedical Engineering Department at TMCA. The Manager of Biomedical Engineering manages the work order generation and completion process. Biomedical Engineering Technicians perform assigned work and return equipment to CCMLS. If necessary, work done by outside contractors is tracked to assure the work is completed in accordance with the terms of a contract.

Hazard Notices and Recalls

Product safety alerts, product recall notices, hazard notices, etc. are received from a variety of external sources. When a piece or type of equipment subject to a hazard notice or recall is identified appropriate action is taken to address the hazard.

PROCESSES OF UTILITY SYSTEMS Design and Maintenance of Utility Systems CBRE is responsible for managing the planning, design, construction, and commissioning of utility systems to meet the operational needs of CCMLS. The construction and commissioning programs are designed to assure compliance with codes and standards and to meet the specific needs of the occupants throughout the facility. In addition, the design process is intended to assure performance capability in excess of current needs to help assure that changing demands on utility systems can be managed without major capital investment. CBRE is responsible for setting maintenance standards and implementing a program of planned maintenance and customer service to ensure a safe comfortable environment.

Emergency Procedures

CBRE has identified and implemented emergency procedures for responding to utility system disruptions or failures.

CBRE has access to a variety of historical documents that graphically illustrate each of the utility systems. Historical documents are being converted, as time allows, to computerized drawings. New utility systems and major updates to existing utility systems are required to be developed by the architect or engineer and provided to CCMLS as computerized drawings. Day-to-day use of historical documents and computerized drawings includes additions, deletions, and other changes to the layout of utility systems to be documented in a timely manner. This ongoing process of making changes allows the overall accuracy of the utility system layout to be maintained at a very high level at all times. Critical or emergency operating components of utility systems are identified on historical documents or computerized drawings. A variety of techniques such as legends, symbols, labels, numbers, and color-coding are used on to identify the location and type of critical or emergency controls. The corresponding physical control is identified by a tag or other device attached to the device. This process is designed to provide technicians with accurate information about the function of a control before it is activated for scheduled maintenance or during an emergency.

Maintenance of Air Filtration, and Filter Efficiency CCMLS is responsible for purchase, maintenance and use of appropriate ventilation equipment to provide appropriate filtration efficiencies for ventilation systems serving areas specially designed to control air-borne contaminants (such as biological agents, gases, fumes, and dust). A qualified service provider is engaged to verify volume flow rates (air exchange rates, and positive or negative pressure rates) and pressure relationships as part of the commissioning of all new building projects and major space renovations. If system performance cannot be adjusted to meet code requirements or occupant needs, CCMLS works with appropriate individuals/departments to develop temporary management practices.

Emergency Electrical Power Systems

CBRE provides reliable emergency power systems that supply emergency power to the following areas when normal electricity is interrupted:

• Alarm systems (e, g, Fire Alarms, and other emergency alarm systems) • Exit route illumination (Lighting in corridors and other key areas to illuminate exit paths

and task areas) • Emergency communication systems (including the PA system, and emergency phone

system elements) • Illumination of exit signs • Reagent and blood storage units in the school

Emergency Power Systems CBRE is responsible for managing a program of inspection, maintenance, and testing of the essential electrical system. Appropriate testing parameters are recorded and evaluated by CBRE. Any indication of performance below code requirements or expectations is immediately evaluated to determine the source of the problem and rectified.

PROCESSES OF THE ENVIRONMENT OF CARE

CCMLS will work with appropriate individuals/departments, including CBRE, to integrate EOC monitoring and response activities into the safety program.

Communication with Leadership & Identification of Performance Improvement Opportunities Findings and concerns, along with relevant supporting materials are communicated to all appropriate individuals/departments. When performance improvement opportunities are identified, a proposal for improvement is prepared and sent to appropriate individuals/departments, which will review all improvement proposals and determine the priority and need for the proposed improvement. Orientation, Training, and Education All faculty/students must attend new employee orientation (at TMCA) within 30 days of hire, or at pre-enrollment orientation. Faculty/students also receive CCMLS safety orientation regarding school-specific hazards, safety processes and their responsibilities.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE EVACUATION ROUTE MAP

Secondary Evacuation Route Primary Evacuation Route To Stairwell & 730 Potomac Lot To Lobby and Main Entrance Lot

HALLWAY

Student Lounge Classroom Lab Door 2 Lab Door 1 Door Door

CCMLS Facility

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Hazardous Materials and Waste Management Plan

Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC PURPOSE: The purpose of the Hazardous Materials and Waste Management Plan is to define the program to identify and manage materials know to have the potential to harm humans or the environment. The plan includes processes designed to minimize the risk of harm. The processes include education, procedures for safe use, storage and disposal, and management of spills or exposures. SCOPE: The Hazardous Materials and Waste Management Plan is designed to address the risks the variety of substances addressed in this plan pose to the environment of The Colorado Center for Medical Laboratory Science (CCMLS), and to the faculty, students and visitors of the organization. The program is also designed to assure compliance with applicable codes and regulations. The program is applied to 730 Potomac St., Suite 102, Aurora, CO FUNDAMENTALS:

1. The scope of the Hazardous Materials and Waste Management Plan is determined by the materials in use and the waste generated by CCMLS.

2. Hazards associated with materials and wastes are defined by law or regulation and are identified in Material Data Safety Sheets (MSDS) or similar documents provided by suppliers and manufacturers.

3. Safe use of hazardous materials and handling of waste requires participation by faculty, students and other appropriate persons in the design and implementation of all parts of the plan.

4. Protection from hazards requires all faculty and students that use or are exposed to hazardous materials and waste to be educated as to the nature of the hazards and to use equipment provided for safe use and handling when working with or around hazardous materials and waste.

5. Rapid, effective response is required in the event of a spill, release, or exposure to hazardous materials or waste.

6. Segregation of hazardous waste at the point of generation is an effective means of controlling the potential for exposures or spills during collection, transport, storage, and disposal.

PROCESSES TO MANAGE THE RISKS:

1. Inventory of Chemicals a. CCMLS maintains a current inventory of the chemicals in the school, along with

the matching MSDS. The chemical inventory and the MSDS will be kept in a labeled binder, and be available to faculty and students. CCMLS leadership

assures the safe selection, storage, handling, use, and disposal of hazardous materials. CCMLS will evaluate Material Safety Data Sheets for hazards before purchase of supplies to assure they are appropriate, and will choose the least hazardous practical alternative.

b. Licensed waste management/disposal contractors and CCMLS will manage the safe storage and handling of chemicals.

2. Waste Labeling

a. All hazardous wastes are labeled from generation to removal. Some wastes, such as biohazardous wastes are labeled by placement in a red bag; other wastes are labeled with specific signs or with text labels

b. Biohazardous waste is placed in red bags, then placed in plastic bins with external labeling as biohazardous wastes, or in a labeled, container which may be provided by the licensed contractor, also labeled with the OSHA Biohazardous labeling. The red bags are deemed to be labeled, as these bags are not used for any other purpose, and any material in a red bag is treated as biohazardous

c. Sharps are placed in labeled, desktop, puncture proof containers, and/or labeled, red, puncture-proof containers provided by the licensed waste removal contractor

d. Chemical waste is labeled on the collection container(s) in accordance with instructions from the licensed chemical waste collection company.

3. Chemicals a. Chemical materials are identified and ordered by faculty. Appropriate storage

space is provided, and chemical materials are maintained in labeled containers. Faculty and students are trained in understanding MSDS information, and in the appropriate and safe handling of the chemicals they use.

b. Chemical materials are labeled throughout their use and handling in the CCMLS facility. The label is on the container prior to receipt, or is placed on containers filled or mixed within the facility

c. Chemical waste is held in the CCMLS facility, as directed by the licensed contractor, until arrival of the licensed contractor. The contractor lab packs the chemicals, completes the manifests and removes the packaged waste. A disposal copy of the manifest is returned to CCMLS to verify legal disposal of the waste.

4. Infectious and regulated medical wastes, including sharps

a. These materials are found in designated areas of the CCMLS facility. The program is designed to identify, separate, collect and control potentially biohazardous materials, and to collect them for licensed disposal. Faculty and students are trained regarding handling materials in these categories. Labeled and specialized containers are used to collect and transport these wastes, and waste removal is manifested by the licensed waste disposal contractor.

b. Regulated medical waste, including sharps, are packaged for disposal, as directed by the licensed waste disposal contractor, and held for the licensed waste contractor pickup. The contactor assists in completing the manifests, and removes the waste, returning the disposal copy of the manifest after final disposal.

5. Spill Plan a. CCMLS faculty and students evaluate spills to determine if outside assistance is

necessary. A minor (incidental) spill (generally less than 1 gallon) that can be effectively cleaned up by the faculty and/or students does not require additional response.

b. A chemical spill that is able to be handled without outside assistance:

i. Notify faculty supervisor(s) ii. Using appropriate personal protective equipment, contain the spill with

absorbent pillow(s) or paper towels and determine if the spilled material is hazardous; if so, remove everyone in the immediate area, access the MSDS and follow instructions for cleanup, including use of appropriate personal protective equipment

c. Spills involving biohazardous material that are able to be handled without outside assistance:

i. Notify faculty supervisor(s) ii. Using appropriate personal protective equipment, contain the spill with

absorbent pillow(s) or paper towels; remove everyone in the immediate area

iii. using appropriate personal protective equipment, wipe up the spill with paper towels, spray the area with approved disinfectant and let sit for a minimum of 10 minutes, wipe up the disinfected spill, dispose of paper towels and gloves in a biohazard waste container. If lab coats, safety glasses, etc. are soiled, place them in the appropriate location for cleaning and/or clean with approved disinfectant. If approved disinfectant is not available, biohazardous spills may be cleaned up with a 1:10 bleach solution (this solution is only viable for 3 days, so containers should be dated and the solution changed as appropriate)

d. A spill that exceeds the capability of the faculty and/or students to neutralize and clean up requires a response from outside the facility. In these cases, faculty supervisor(s) are notified, the area is evacuated, ventilation controlled, and the Aurora Fire Department is called (911). The Fire Department takes control of the site and cleanup, or arranges for it to be cleaned up. Once determined safe, faculty and/or students may finish the cleanup and recovery. Faculty and students are trained to recognize the potential for a spill that is not safe to handle, and to contact their supervisor and/or the Building Management Office for TMCA North (CBRE). Faculty and students are cautioned to err on the side of safety, and not to handle spills that exceed their training, or the personal protection that is available.

6. Separation of Waste Handling Areas a. CCMLS maintains appropriate handling and storage areas for hazardous wastes

that are separated and maintained to minimize the possibility of contamination of food, clean and sterile goods, or contact with faculty, students or visitors.

b. Hazardous wastes are moved in covered or closed containers, from holding areas to the storage space designated for processing and handling those wastes.

c. Routing of materials during transport is determined to minimize contact with visitors, and to protect faculty and students and the facility from contamination.

7. Orientation, Training and Education a. All faculty and students must attend the HCA HealthONE employee orientation

within 30 days of hire/start of classes. New employee orientation addresses key safety and security issues.

b. Faculty and students also attend CCMLS safety orientation regarding hazards, their responsibilities, and specific procedures.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Hazard Communication Program Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC INTRODUCTION: On November 25, 1983, the original OSHA Hazard Communication Standard, also known as the employee “Right-to-know” law, was published to ensure that the hazards of all chemicals produced or imported are evaluated by the manufacturers or importers and that the information concerning their hazards is transmitted to employers and employees. The original standard only applied to manufacturers, importers and distributors of hazardous chemicals and employers in the manufacturing sector, SIC 20-39. However, on September 23, 1987, the Hazard Communication Standard was expanded to include all business factors, including health care facilities. This law requires employers to transmit information on hazardous chemicals to employees who are potentially exposed through means of container labeling, material safety data sheets, and training programs. POLICY: The Colorado Center for Medical Laboratory Science (CCMLS) acknowledges that every faculty/student is entitled to work/participate in educational activities under the safest possible conditions. CCMLS intends to communicate information on hazardous chemicals to faculty/students that have the potential to be exposed by means of this written Hazard Communication Program. The elements of the program shall be maintained in a Safety Manual which shall be available to faculty/students that have the potential for chemical exposure whenever they are working/participating in educational activities. RESPONSIBILITIES:

A. CCMLS Program Director and/or designee: 1. implement the written program 2. conduct chemical inventories 3. obtain MSDS’s 4. assure proper labeling of chemical containers 5. individualize the program for effectiveness within the department 6. comply with and enforce the policies and procedures of this program in the

safe handling of chemicals 7. limit the amount of chemicals located in the area by purchasing quantities

that can be used within a reasonable amount of time 8. limit the hazardous chemical inventory by not introducing unnecessary

chemicals into the work place 9. reduce the hazardous chemical inventory by eliminating chemicals which

are no longer used or that are “out of date” through proper disposal methods

B. MOB Management Compancy (CBRE): 1. ensure that contractors who may be exposed to hazardous

chemicals/products used in CCMLS are properly informed of the potential hazards

2. ensure that contractors inform CCMLS faculty of any hazardous chemicals/products that they may bring into the facility.

C. CCMLS Faculty: 1. request MSDS’s for chemicals when ordering 2. ensure that incoming products are labeled correctly and that MSDS’s are

provided in the initial shipment 3. distribute MSDS’s to CCMLS Program Director or designee as appropriate

D. CCMLS Faculty and Students: 1. comply with the policies and procedures outlined in this program in the safe

handling and storage of chemicals 2. are knowledgeable in the location and contents of MSDS in CCMLS 3. report to the Program Director and/or faculty any unlabeled containers,

spills or other problems concerning chemical safety 4. attend all mandatory training sessions

SAFETY MANUAL CCMLS maintains a Safety Manual that contains the Hazard Communication Program, an inventory of chemicals used/stored at CCMLS, a copy of OSHA’s Hazard Communication Standard (HAZCOM), and a notebook that contains all MSDS for each chemical listed on the inventory. These items are available to faculty/students at all times when they are in the facility. PROCEDURES

A. Chemical Inventory 1. A chemical inventory will be included in the CCMLS Safety Manual. 2. CCMLS is responsible for maintaining the inventory by adding or deleting

any product name when the situation occurs 3. The chemical inventory will be reviewed and updated annually.

B. Material Safety Data Sheets (MSDS) – the single, most important elements of this program as they provide the information needed by individuals to protect themselves from chemical hazards. The department MSDS notebook shall be available to faculty/students at all times when they are in the facility. Faculty/students shall be provided copies of MSDS upon request. The following guidelines shall be followed to insure that an MSDS for each hazardous chemical is available: 1. CCMLS will obtain a MSDS for existing or new chemicals (gases, liquids,

and solids) used or stored within CCMLS. Exceptions or exclusions to the standard include those consumer products that are used at CCMLS with the same frequency as normal home use. Also not included under the jurisdiction of the HAZCOM standard are hazardous wastes regulated under RCRA and drugs in sold and final form (pills) for direct administration to patients. In general, pharmaceuticals are governed by the FDA and therefore, are excluded from this program.

2. When a new or updated MSDS for a chemical used within CCMLS is received, it shall be forwarded to the Program Director or designee, who is responsible for maintaining the MSDS notebook.

3. The following information is normally included on the MSDS:

a. chemical identity used on the label, both chemical and common names

b. physical and chemical characteristics c. physical hazards d. health hazards e. primary routes of entry f. OSHA permissible exposure limit and any other exposure limits g. Whether the chemical is listed as a carcinogen h. Precautions for safe use and handling i. Control measures j. Emergency and first aid procedures k. Date the MSDS was prepared l. Name, address, and telephone number and/or e-mail address of

the chemical manufacturer 4. When products are purchased from a local retail distributor (ie. paints,

stains, varnishes, etc.), it is the responsibility of the person purchasing the product(s) to request and obtain a MSDS from either the distributor or manufacturer, and forward the MSDS to the Program Director or designee.

C. Labeling – personnel receiving the chemicals shall be responsible for assuring that all incoming chemicals/products follow the labeling requirements listed below: 1. Each chemical container shall be labeled with the following information:

a. identity of hazardous chemical, including any chemical or common name that is indicated on the MSDS. The identity must correspond with the label, MSDS and inventory list.

b. Appropriate hazard warnings – any message, words, pictures or symbols are allowed as long as they convey the hazards of the chemical. It is not necessary to address every hazard on the label. The hazards should be weighed and assigned to the label accordingly; manufacturer’s labels may be used as a guide.

c. Name and address of the chemical manufacturer, importer or other responsible party

i. Exception – portable containers into which hazardous chemicals are transferred from labeled containers and which are intended only for immediate use. Immediate use means that the chemical will be under the control of and used by only the person who transfers it and only within the “work shift” in which it is transferred.

2. Labeling information must be in English. Pictorial or numerical systems may be used for non-English speaking faculty/students.

3. When chemicals are transferred from large containers to small containers, they need to be properly labeled.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Bloodborne Pathogen Exposure Control Plan

Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC PURPOSE: The purpose of the bloodborne pathogen exposure control plan is to define the program to identify and manage materials known to have the potential to harm humans or the environment. The plan includes processes designed to minimize the risk of harm. The processes include education, procedures for safe use, storage and disposal, and management of spills or exposures. SCOPE: It is the policy of The Colorado Center for Medical Laboratory Science (CCMLS) to protect the health and well-being of its faculty and students who may become exposed to bloodborne pathogens (BBP). This plan has therefore been developed to apply the provisions of the Occupational Safety and Health Administration's Occupational Exposure to Bloodborne Pathogen Standard 29 CFR 1910.1030 and the Centers for Disease Control recommendations for isolation practices in hospitals as published by the CDC in 2007. (http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf). This plan includes the following components: Identification of individuals who have occupational exposure risk Procedure to evaluate exposure incidents Engineering and work practice controls Personal protective equipment practices Housekeeping procedure Faculty and Student training Standard Precautions/practices Provisions for Hepatitis B vaccine for faculty and students Documentation and record-keeping Both the Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control (CDC) recognize that blood and some body fluids may contain potentially infectious pathogens, and believe that all blood and other potentially infectious materials (OPIM) may be treated in such a manner as to reduce the risk of transmission of disease. These pathogens include, but are not limited to, Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV). Other pathogenic microorganisms present in human blood or OPIM that can infect and cause disease in persons who are exposed to blood containing the pathogen are malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob

disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever. Exposure Determination Policy: Definition: Occupational Exposure--A reasonable anticipated skin, eye, mucous membrane or parenteral

contact with blood or OPIMs that may result in the performance of faculty/student educational activities/duties.

It has been determined that the following classifications have an actual or potential risk of exposure to blood and OPIMs. These individuals are therefore covered by, and must comply with, the BBP Exposure Control Plan. Classifications in which ALL individuals have exposure to bloodborne pathogens: 1. CCMLS Faculty – salaried, contract, part time, guest 2. CCMLS Students 3. CCMLS Support Individuals, including, but not limited to laboratory staff that are assisting with educational activities and specimen procurement Classifications in which SOME individuals may have exposure to bloodborne pathogens: 1. Biomedical Engineers 2. Plant Operations Staff 3. Couriers/Van Drivers 4. Housekeeping Staff 5. Laundry Workers 6. Volunteers Tasks and procedures with potential exposure to bloodborne pathogens: Vascular access procedures Handling contaminated sharps, instruments, or equipment that has been used in patient care Obtaining, handling, and processing laboratory specimens Handling and administering blood products Cleaning equipment and working surfaces Handling, transporting, and/or processing infectious waste Handling/repairing equipment that has been visibly contaminated with blood Direct patient care when contamination from blood and other body fluids is anticipated Handling, transporting, and/or processing of soiled linen Giving emergency care

METHODS OF COMPLIANCE: This Exposure Control Plan identifies specific areas to effectively eliminate or minimize exposure to bloodborne pathogens at CCMLS, clinical affiliates and other locations where educational activities occur. Each of these areas are reviewed with faculty/students during orientation sessions, upon hire, annually, and whenever essential (i.e. following an exposure, request for in-service, etc.).

Standard Precautions: Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. In circumstances where it is difficult to differentiate between fluids, it will be assumed that all body fluids are potentially infectious. Standard Precautions will be utilized throughout CCMLS, clinical affiliates and other locations where educational activities occur. All human blood and other potentially infectious materials are treated in the same manner. Standard Precautions apply to:

1. blood 2. all body fluids, secretions, and excretions (except sweat), regardless of

whether or not they contain visible blood 3. non-intact skin 4. mucous membranes

Engineering Controls: Engineering controls are designed to eliminate or minimize exposure to bloodborne pathogens. Engineering control items are reviewed for proper functioning and needed repairs or replacement, whenever necessary and/or annually. Faculty/students should contact the program director if additional engineering controls are recognized as being needed or desired. Safety products are presented and evaluated as they become available. Additionally, the need for different or new engineering controls/safety devices may be identified during an investigation of an exposure incident. The following engineering controls/processes may be used throughout CCMLS, clinical affiliates and other locations where educational activities occur:

1. Hand washing facilities and/or alcohol based hand sanitizers 2. Contaminated needles and other contaminated sharps will not be bent, recapped,

broken or otherwise manipulated. In rare situations where recapping of needles is necessary, the one-handed technique may be used: The hand holding the sharp is used to scoop up the cap from a flat, hard surface and immediately discarded into a sharps container. This procedure is to be performed in a safe manner and is limited to situations in which recapping is necessary.

3. Containers for contaminated sharps 4. Once engaged, all self-sheathing safety products will be disposed of in a sharps

container. 5. Containers for contaminated sharps are provided by and replaced routinely by an

outside contractor and not allowed to overfill. When the "fill marker" is reached, the contractor will be notified to replace container.

6. Specimen containers are leak-proof, color-coded, or labeled with biohazard warning label.

7. Secondary containers for specimens are leak-proof, color-coded, or labeled with biohazard warning label, and puncture-resistant if necessary.

Work Practice Controls:

The following work practice controls are in effect throughout CCMLS, clinical affiliates and other locations where educational activities occur:

1. Faculty/students will wash hands immediately or as soon as feasible after removal of gloves or other personal protective equipment (PPE).

2. Following contact of body areas with blood or OPIMs present, faculty/students will wash their hands and any other exposed skin with soap and water and/or alcohol-based hand sanitizers as soon as possible.

3. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses will be prohibited in areas where there is potential for exposure to bloodborne pathogens or other epidemiologically important pathogens.

4. Food and drink will not be kept in refrigerators, freezers, on counter tops, or in other storage areas where blood or OPIMs are present.

5. Contaminated needles and other sharps are not bent, recapped, or removed unless it can be demonstrated that there is no feasible alternative, or if the action is required by a specific procedure.

6. Contaminated reusable sharps are placed in appropriate containers immediately, or as soon as possible, after use.

7. Mouth pipetting/suctioning of blood or OPIMs is prohibited. 8. All procedures involving blood or OPIMs will be done in such a way as to minimize

splashing, spraying, or generating droplets. 9. Specimens of blood or other materials are placed in designated leak-proof

containers appropriately labeled, for handling and storage. 10. A specimen container is placed within a second leak-proof plastic biohazard bag

appropriately labeled, for handling and storage. 11. All precautions and standards for manual transport of specimens also apply to the

automated transport of specimens (including containing, tagging and labeling). 12. Equipment that becomes contaminated is examined prior to servicing or shipping,

and decontaminated as necessary; unless it is determined that decontamination is not feasible.

13. An appropriate biohazard-warning label will be attached to any contaminated equipment, identifying the contaminated portions.

14. Information regarding the remaining contamination will be relayed to all affected employees, the equipment manufacturer, and the equipment service representative prior to handling, servicing, or shipping.

15. Faculty/students will be trained by the program director or designee in the appropriate work practice controls.

Personal Protective Equipment (PPE):

“Appropriate” PPE is used to protect faculty/students against exposure to bloodborne pathogens. PPE is "appropriate" if it does not permit blood or other potentially infectious materials to pass through to or reach faculty/student work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use, and for the duration of time which the PPE is used. This equipment includes, but is not limited to: Gloves – Latex free gloves and glove liners are available Masks

Goggles or glasses with solid side shields Laboratory coats Face shields CCMLS provides PPE to all faculty/students, with the exception of student safety glasses & masks for COVID-19 protocols (students are required to provide their own safety glasses and masks for COVID-19 protocols). Additionally, all faculty/students are trained regarding the use of appropriate PPE during orientation, and as otherwise necessary. Training includes, but is not limited to: The proper use of PPE The accessibility of PPE (i.e., appropriate glove size, lab coats, location of PPE) Cleaning schedule of reusable equipment Repair and replacement of PPE as needed Faculty/students will use appropriate PPE except under rare and extraordinary circumstances when, based on faculty/student professional judgment, the use of such equipment would prevent the delivery of safe healthcare or would pose an increased hazard to the safety of the faculty/student or patient. When the faculty/student makes this judgment, the circumstances will be documented and investigated in order to determine where changes can be instituted to prevent such occurrences in the future. CCMLS will clean, launder, and dispose of the PPE required under this plan at no cost to the faculty/student, with the exception of student safety glasses. To ensure that PPE is used as effectively as possible, faculty/students that are subject to exposure will adhere to the following practices: 1. Any garment(s) that are penetrated by blood or other infectious materials are removed

immediately or as soon as feasible. 2. All PPE is removed prior to leaving a school/work area (any area in the school/work place

where exposure to blood or other potentially infectious materials is possible). 3. When PPE is removed, it will be placed in an appropriately designated area or container for

storage, washing, decontamination, or disposal. 4. Gloves of appropriate size will be:

a. Worn when touching blood, body fluids (secretions or excretions), and contaminated items

b. Worn when touching mucous membranes and non-intact skin c. Changed between clean and dirty procedures on same patient d. Removed promptly after use, before touching non-contaminated items and environmental

surfaces, and before going to another patient e. Used for all vascular access procedures f. When handling or touching contaminated items or surfaces g. Disposable (single use) gloves such as surgical or examination gloves will be replaced as

soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when the ability to function as a barrier is compromised.

h. Disposable gloves will not be washed or decontaminated for re-use. i. Utility gloves may be decontaminated 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 the ability to function as a barrier is compromised.

5. Masks will be worn in combination with eye protection (with side shield protection) and face shields during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids (excretions and secretions).

6. Appropriate protective clothing will be worn in exposure situations. The type and

characteristics will depend upon the task and degree of exposure anticipated. a. If, at any time, faculty/student clothing other than PPE becomes soiled with blood or

other potentially infectious materials, CCMLS will provide instructions for removal, transport and laundering of this clothing.

Housekeeping:

CCMLS will be maintained as a clean and sanitary workplace. To facilitate this, the following practices will be used: 1. All equipment and surfaces are cleaned and decontaminated after contact with blood or

other potentially infectious materials a. After the completion of medical procedures b. Immediately (or as soon as feasible) when surfaces are overtly contaminated c. After any spill of blood or infectious material

2. Protective coverings (such as plastic wrap, aluminum foil or absorbent paper) are removed and replaced as soon as feasible when overtly contaminated.

3. All pails, bins, cans, and other receptacles intended for use are routinely inspected, cleaned, and decontaminated with an appropriate disinfectant as soon as possible if visibly contaminated.

4. Potentially contaminated broken glassware is picked up using mechanical means (such as dustpan and brush, tongs, forceps, etc.).

5. Contaminated reusable sharps are stored in containers that do not require "hand processing".

6. Contaminated sharps (including those sharps with a re-sheathing mechanism engaged) are discarded immediately or as soon as feasible in containers that are closeable, puncture-resistant, leak-proof on sides and bottom, and labeled or color-coded in accordance with the Communication of Hazards section of this plan.

7. During use, containers for contaminated sharps will be: a. Easily accessible to personnel and located as close as feasible to the immediate area

where sharps are used or can reasonably be anticipated to be found. Containers are maintained upright throughout use.

b. Removed and replaced by licensed contractor, and not allowed to overfill. 8. Needle containers will not be opened, emptied, cleaned, or handled in any manner that

would expose faculty/students to the risk of percutaneous injury. 9. Regulated waste will be placed in containers which are closeable; constructed to contain all

contents, and prevent leakage during handling, storage, transport or shipping, and labeled or color-coded according to the Communications of Hazards section of this plan; and closed prior to removal to prevent spillage or protrusion of contents.

10. If outside contamination of the regulated waste container occurs, it will be placed in a secondary container by the licensed contractor that will be closeable and constructed to contain all contents and prevent leakage during handling, storage, transport or shipping; and labeled or color-coded according to the Communications of Hazards section of this plan.

11. Disposal of all regulated waste will be in accordance with applicable federal, state, and local laws and regulations.

12. Contaminated/soiled linen will be handled as little as possible and in a way to prevent contamination to self and the environment. All soiled linen is considered contaminated and will be placed in impervious linen bags at the location of use. A single impervious linen bag is adequate; linen does not have to be double bagged.

13. MOB Housekeeping Department cleans CCMLS on a regular basis and as otherwise necessary. Faculty/students do all other “spot cleaning” and decontamination necessary.

Blood Spills:

Whenever there is a spill of blood or OPIMs, the faculty/student will: 1. Put on the appropriate PPE 2. Wipe up the spill with paper towel or cloth towel. 3. Pour appropriate disinfectant or a 1:10 bleach and water solution (made fresh daily), onto the

area and leave on a minimum of ten minutes. Wipe it up making sure that the area is completely dry.

4. Discard all materials appropriately (in infectious waste container or impervious linen bag). Responsibilities:

1. CCMLS faculty will: a. Implement the Bloodborne Pathogen Exposure Control Plan (ECP) for CCMLS b. Work with Administration and other departments to develop and administer any

additional policies and procedures to support implementation of the plan c. Review and revise the ECP as necessary d. Be aware of current legal requirements concerning bloodborne pathogens. e. Ensure control and training, including orientation of new faculty/students and annual

training for continuing faculty/students. f. Maintain training documentation records for a minimum of three years. g. Review and revise the training program as necessary.

2. CCMLS Faculty/Students will:

a. Know what tasks they perform that have risk of exposure. b. Attend a bloodborne pathogen training session on an annual basis. c. Comply with all policies and procedures regarding BBP, Standard Precautions, and

exposure to BBP. d. Keep the Program Director apprized of their Hepatitis B vaccination status and their

training session attendance.

Hepatitis B Vaccination and Post-Exposure Follow-Up: CCMLS recognizes that exposure incidents can occur even with good adherence to exposure prevention practices. Because of this risk, CCMLS has implemented a Hepatitis B Vaccination Program (described below) that includes procedures for post-exposure evaluation and follow-up, should an exposure to bloodborne pathogens occur. Hepatitis B Vaccination: Prophylactic Hepatitis B vaccine is required for students prior to the start of classes. Students are responsible for submitting documentation and/or obtaining the vaccine. The vaccine is available to faculty during the pre-employment health screen within ten (10) working days of initial employment to those who have potential for exposure unless the individual has previously received the Hepatitis B vaccine series; antibody testing has shown that the employee is immune to Hepatitis B; if the vaccine is contraindicated for medical reasons or the faculty/student refuses the vaccination, he/she must sign a declination form reflecting such.

Faculty/students may later decide to receive the vaccine and in that event, they will be vaccinated. The vaccination program consists of a series of two vaccinations (Heplisav-B) or a series of three inoculations over a six-month period. As part of the bloodborne pathogens education, faculty/students receive information regarding Hepatitis B vaccination, including its safety and effectiveness. Faculty/students who have a history of Hepatitis B infection will have a hepatitis B surface antigen (HBsAg) and a Hepatitis B core antibody (anti-Hbc) drawn. Vaccinations are performed by a licensed healthcare professional by a designated provider. Faculty/students who have declined to take part in the program have signed a "Vaccination Declination Form" and records are maintained by the designated provider.

Post-Exposure Evaluation and Follow-Up (Needlesticks, Percutaneous, Mucous Membrane & Skin Contact):

Definition: Bloodborne Pathogen Exposure (BBPE): a percutaneous injury (e.g., a needle stick or cut by a sharp object), contact with mucous membranes, or contact of skin (especially when the exposed skin is chapped, abraded, or afflicted with dermatitis, or the contact is prolonged or involves an extensive area), of blood, human tissues, or other body fluids to which Standard Precautions apply including: a) semen and vaginal secretions, b) cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid and amniotic fluid; c) other body fluids contaminated with visible blood; and d) laboratory specimens that contain IV or HBV, HCV. Faculty/Student Responsibility:

Upon sustaining a bloodborne pathogen exposure, faculty/students must: 1. Immediately wash the exposed area thoroughly with soap and water. 2. Report the injury/exposure to the supervisor on duty at the time of incident. 3. If the exposure occurs during a clinical rotation, complete the Workers’ Compensation

insurance form (available on CCMLS website), immediately contact the designated provider for evaluation, screening, prophylactic treatment, and counseling. During off-hours, weekends, and holidays, the faculty/student will seek immediate care as required (personal physician, emergency department, etc.) for evaluation, counseling, and treatment. The faculty/student will follow-up with the designated provider on the next business day. Faculty/student must bring the Workers’ Compensation insurance form to healthcare provider, provide a copy of the completed form to the CCMLS Program Director or his/her designee within 24 hours. If the exposure occurs during a student lab session, it should be reported to supervising faculty, and a report submitted according to school policy. During student lab terms, students are responsible for all expenses.

4. Complete an Injury/Illness report as applicable within 24 hours and provide a copy to the CCMLS Program Director or his/her designee.

• If possible, document source-patient information including name, room number and physician

• Provide a detailed description of how the exposure occurred

• Provide size, type and brand of “sharp” used, if applicable. 5. Complete lab testing and follow-up treatment as directed/recommended

6. .Supervisor/Department Director Responsibility: The Supervisor in charge at the time of the exposure will:

1. Immediately refer the faculty/student to the designated provider for evaluation, counseling, and treatment.

2. If possible, facilitate testing of the source. 3. If possible, verify that source information is documented on the Injury/Illness Report 4. Complete the supervisor section of the Injury/Illness Report.

Health Care Provider Responsibility: The designated health care provider will complete the following according to their protocol: 1. Complete assessment of the exposure 2. Initiate referral for Post-Exposure Prophylaxis and initiate additional follow-up lab tests,

vaccination, etc, including, but not limited to, Hepatitis B immunity status, HCV status, other testing as indicated.

3. Complete investigation of the incident. Complete the Injury/Illness Report (if applicable), and appropriate insurance form(s) for reporting to the insurance carrier and regulatory agencies as required.

4. If the source is identified, the health care provider (if possible) will request and ensure collection of blood for testing of the source per protocol. (Per Colorado statute, post-exposure HIV testing does not require source consent). 5. Confidentiality of faculty/student lab tests and results will be maintained. Faculty/students will be provided with follow-up testing and prophylactic treatment as outlined.

• Results of additional follow-up testing may be provided according to protocol. • Follow-up results and notification are documented according to protocol • All declinations of recommended or offered treatment will be documented according to

protocol Faculty/students will be provided with education and counseling following bloodborne pathogen exposures. 1. The Health Care Provider will provide counseling according to protocol which may include:

a. General information about HIV, the disease process, and the prophylactic treatment and follow-up responsibilities of the employee.

b. General information about Hepatitis B, the disease process, indications for Hepatitis B vaccine and follow-up responsibilities of the faculty/student.

c. General information about Hepatitis C, the disease process and lack of prevention/treatment modalities available.

2. A referral will be made to the appropriate provider for additional counseling and/or evaluation according to protocol, which may include: a. exposure assessment and coding indicates prophylactic treatment may be warranted b. requests by the faculty/student c. follow-up faculty/student testing is positive for HIV or HBV d. source is know to be HIV and/or HbsAg positive

Faculty/student counseling may include discussions regarding:

Information about Hepatitis B infection, vaccination and incubation period for HBV Information about Hepatitis C infection Information about HIV infection, treatment and incubation period follow-up responsibility of faculty/student In the event a volunteer, guest faculty, etc. sustains a bloodborne pathogen exposure: 1. The incident must be immediately reported to the Program Director or his/her designee,

and/or to the supervisor in charge at the location and time of the incident. 2. The volunteer, guest faculty, etc. will follow the protocol for faculty/students above 3. Cost for testing and follow-up are not covered under the CCMLS Workers’ Compensation

program. The designated provider forwards a copy of the Injury/Illness Report form (if applicable) and the Workers’ Compensation insurance form to the CCMLS program director or his/her designee. Further investigation, as needed, will follow and may include: Follow-up with the supervisor Availability and use of the personal protective equipment Availability and use of engineering controls Demographic and employment data about the employee Adherence to work practice controls and/or other safety policies

Communication of Hazards to Faculty/Students: Warning labels will include the universal biohazard symbol followed by the term "biohazard". The biohazard label must be fluorescent orange or orange-red, with lettering or symbols in a contrasting color. The labels must be either an integral part of the container or affixed as close as feasible to the container by a string, wire, adhesive, or other method that prevents their loss or unintentional removal. Other labeling messages may be included as long as they do not detract from the visibility of the "biohazard" label. Labeling is NOT required for:

• Containers of blood, blood components and blood products labeled as to their contents and released for transfusion or other clinical use because they have been screened for HBV, HCV and HIV prior to their release

• Individual containers of blood or other potentially infectious materials that are placed in secondary labeled containers during storage, transport, shipment, or disposal

• Specimen containers, since CCMLS uses Standard Precautions for handling all laundry and regulated waste that has been decontaminated.

The following procedures for communicating hazards to employees will be used:

• Warning labels will be affixed to containers of regulated waste, contaminated equipment, refrigerators and freezers containing blood or other potentially infectious materials, and other containers used to store, transport, or ship blood or other potentially infectious materials.

• Warning labels will be in the colors described above. • Red biohazard bags or red containers may be substituted for labels.

• Warning labels required for contaminated equipment will also state which portions of the equipment remain contaminated.

Information and Training: CCMLS will ensure that all faculty/students that are at risk for exposure participate in a training program. Training will be provided at the time of orientation/initial employment and at least annually thereafter. All faculty/students will attend the New Employee Orientation Program at TMCA (or other designated HCA HealthONE facility) and the CCMLS orientation. CCMLS will provide additional training when changes occur such as modification of tasks or procedures or institution of new tasks or procedures that affect the faculty/student's occupational exposure. The additional training may be limited to addressing the new exposure created. Material appropriate in content and vocabulary to educational level, literacy, and language of faculty/students will be used. The person conducting the training will be knowledgeable in the subject matter required to be covered by the training program as it relates to the faculty/students being addressed. Training Topics: Topics covered in the training program may include: The Bloodborne Pathogens Standard, 29 CFR, l9l0.l030, and an explanation of the

standard’s contents. A general explanation, including the epidemiology and symptoms of bloodborne diseases. An explanation of the modes of transmission of bloodborne pathogens. Appropriate methods for recognizing tasks and other activities that may involve blood and

other potentially infectious materials. A review of the use and limitations of methods that will prevent or reduce exposure, including

engineering controls, work practice controls, and PPE. Selection and use of PPE including types available, proper uses, location within workplace,

removal, handling, decontamination, and disposal techniques. Visual warnings of biohazard within the facility including labels, signs, and "color-coded"

containers. Actions to take and persons to contact in an emergency involving blood or other potentially

infectious materials. Information that the facility provides on the post-exposure evaluation and follow-up, including

a medical consultation when indicated. Training Methods: HCA-HealthONE and CCMLS training presentations make use of several training techniques that may include: Classroom-type atmosphere with personal instruction Training manuals/handouts Review sessions

Time is specifically allocated for questions and interaction with the instructor. Documentation:

1. Copies of all documents that are relevant/produced in the investigation and treatment of

an exposure incident are kept on file at CCMLS and TCHF for at least three years.

Infectious Waste Management Program The CCMLS Program Director in coordination with other appropriate individuals/departments will manage the Infectious Waste Management Program for CCMLS. Definition of Infectious Waste: For purposes of this document, infectious waste is defined as waste capable of producing an infectious disease. This definition requires a consideration of certain factors necessary for induction of disease. These factors include: Presence of pathogen Dose Portal of entry Resistance of host For a waste to be considered infectious, it must contain pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease. Infectious waste is designated by the Infection Control Department at TMCA and may include (this list is not all-inclusive): Contaminated hypodermic needles/syringes Contaminated scalpel blades, pipettes and broken glass Pathology specimens Used blood or blood product bags and tubing Disposable culture dishes Discarded live and attenuated vaccines Waste blood, serum, plasma and blood products Soiled dressings, perineal pads, sponges, drapes, lavage tubes, drainage sets, suction canisters and contents, underpads, surgical and examination gloves Specimen containers, slides and cover slips Masks, gowns, disposable eyewear (goggles), and disposable face shields IF

visibly soiled with blood or other potentially infectious materials All waste designated as infectious as outlined above will be separated in the following manner: A rigid, puncture-resistant and leak-proof storage container that is lined with a red infectious

waste bag will be located in appropriate areas of the student laboratory. All infectious waste, except sharps, will be placed into the autoclavable plastic bag within the marked container. All sharps will be placed into the designated and labeled “sharps” container. No additional handling of infectious waste should occur until the red Infectious Waste Container is removed by the designated contractor or other individual so designated by the CCMLS Program Director. This rigid container will be transported outside the building to a holding area for storage. The workers who transport and handle infectious waste according to the protocol of the contractor. The rigid container with infectious waste is stored in a designated area. The containers are picked up regularly by an independent, licensed contractor and transported to their facility for treatment and disposal. Neutralization, disposal, and transportation of all sharps containers and infectious waste are

handled by a licensed, contractor in accordance with a signed agreement. Monitoring procedures related to sharps containers and infectious waste is the responsibility of CCMLS and the contracted service. In the event of spills or loss of containment, the following procedures will be followed: The labeled container will be relined with an autoclavable red bag Personnel wearing appropriate PPE and gloves will place spilled materials into new liners;

normal disposal procedures will be followed. The spill area will be disinfected with a properly diluted solution of approved disinfectant as

described under Blood Spills, above.

Glossary (Definitions) The following definitions will apply to the Exposure Control Plan: Blood: human blood, human blood components, and products made from human blood. Bloodborne Pathogens: pathogenic microorganisms that are present in human blood and cause disease in humans. These pathogens include, but are not limited to, Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV). Other pathogenic microorganisms which can also cause disease are malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma caused by HTLV-I), HTLV-I associated myelopathy, diseases associated with HTLV-II and viral hemorrhagic fever. Contamination: the presence or reasonable anticipated presence of blood or other potentially infectious materials on an item or surface. Contaminated Laundry: laundry that has been soiled with blood or other potentially infectious materials or may contain sharp objects ("sharps"). Contaminated Sharps: any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires. Decontamination: 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. Engineering Controls: controls (e.g., sharps disposal containers, self-sheathing needles) that isolate or remove the bloodborne pathogens hazards from the workplace. Exposure Incident: a specific eye, mouth, other mucous membrane, non-intact skin (skin with dermatitis, hangnails, cuts, abrasions, chafing, acne etc.), or parenteral contact with blood or other potentially infectious materials that result from the performance of faculty/student duties. Occupational Exposure: reasonable anticipated skin, eye, mucous membrane, or parenteral

contact with blood or other potentially infectious materials that may result from the performance of faculty/student duties. Other Potentially Infectious Materials (OPIM): refers to the following human body fluids: semen, vaginal secretion, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. Parenteral: piercing mucous membranes or the skin barrier through such events as needle sticks, human bites (which break the skin), cuts and abrasions. Personal Protective Equipment (PPE): specialized clothing or equipment worn by faculty/students for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts, or blouses, some scrubs) not intended to function as protection against a hazard are not considered personal protective equipment. Regulated Waste: liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. Source Individual: any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the faculty/students. Sterilize: the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores. Standard Precautions: strategy used for successful Infection Control. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. Work Practice Controls: controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Tuberculosis Plan Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC Purpose: To establish guidelines for reducing the risk of transmission of tuberculosis. Policy: It is the policy of The Colorado Center for Medical Laboratory Science (CCMLS) to protect the health and well-being of its faculty/students that may be exposed to Mycobacterium tuberculosis (TB). This plan has been developed to apply the provisions of the Occupational Safety and Health Administration Guidelines for preventing the Transmission of Tuberculosis in healthcare facilities. Individuals Responsible for Implementation of the Plan: 1. CCMLS will be responsible for implementation of the TB Plan in the school facility. 2. Infection Preventionists, Employee Health Nurses, Plant Operations personnel, Department

Directors and other healthcare workers as appropriate will be responsible for implementation of TB Plans in clinical facilities.

3. All Faculty/students will: know what tasks they perform that have occupational exposure attend a TB educational offering at hiring or pre-enrollment orientation comply with the guidelines of the plan.

TB Prevention Procedures: 1. Education and Training: CCMLS will ensure that all faculty/students with potential

occupational exposure to TB participate in a training program that will be provided at no cost. Training will be provided at the time of initial employment or pre-enrollment orientation. Additional training will be provided as needed. A. Material appropriate in content and vocabulary to educational level, literacy, and

language of faculty/student, will be used. B. The person conducting the training will be knowledgeable in the required subject matter

being covered as it relates to the faculty/students being addressed. C. Training may include discussion of the following: the basic concepts of TB transmission, pathogenesis, and diagnosis, including the

difference between latent TB infection and active TB disease, the signs and symptoms of TB, and the possibility of reinfection or reactivation in persons with a positive Tuberculin Skin Test (TST)

the potential for occupational exposure to persons with infectious TB in the healthcare facility, including prevalence of TB in the community and facility, the ability of the facility to appropriately isolate patients with active TB, and situations with increased risk of exposure to TB

the principles and practices of infection control that reduce the risk of transmission of TB, including the hierarchy of TB infection control measures, and the written policies

and procedures of the facility the purpose of TST testing and the significance of a positive result the responsibility of the faculty/student to seek medical evaluation promptly if

symptoms develop that may be due to TB, or if TST conversion occurs in order to receive appropriate evaluation and therapy, and to prevent transmission of TB to others

the importance of notifying the CCMLS Program Director if diagnosed with active TB the responsibilities of CCMLS to maintain the confidentiality of the faculty/student while

assuring that the faculty/student with TB receives appropriate therapy and is non-infectious before returning to duty/classes

TB Surveillance and Treatment:

1. Tuberculin Skin Test ( TST) Tuberculin Skin Test - The Mantoux technique (intradermal injection of 0.1 ml of purified

protein derivative containing 5 tuberculin units) may be used as a diagnostic aid to detect tuberculosis infection.

Two-Step Testing Procedure - The specific procedure for administering the two-step Mantoux begins with an initial test using the Mantoux method with 5 tuberculin units (TU) or 0.1 ml of purified protein derivative. This test should be read at 48 to 72 hours. If the reaction is 10 mm or more induration, the result should be recorded as a significant or positive reaction, and a chest x-ray will be performed at P/SLMC as soon as possible. A Quantiferon Gold blood test may also be ordered to confirm results. If the reaction is not significant (< 10 mm), a second test should be administered one to three weeks after the first test, and read the usual 48-72 hours later. If the second test results in a reaction of 10 mm or greater, the patient should receive further medical evaluation.

New employees/students with a positive TST or positive Quantiferon Gold are referred to their primary care physician PCP) with a copy of their test results.

Interpretation Readings should be taken in good light, with the forearm slightly flexed at the elbow,

with the arm relaxed. The basis of the reading is the presence or absence of induration, which may be

determined by inspection (from a side view against the light as well as direct light), and by palpation with gentle stroking of the finger.

2. Quantiferon®-TB Gold In-Tube Test The Quantiferon®-TB Gold In-Tube Test is a blood test that helps detect TB infection. The test is extremely specific and sensitive for Mycobacterium tuberculosis with an accuracy of 99.3%. In addition, the test is unaffected by BCG vaccination, steroids, and other non-tuberculosis Mycobacteria. The Quantiferon testing may be used in the following cases: Those with known positive skin tests, if medically indicated Those with previous reaction to TST Those for which the skin test is medically contraindicated, such as

immunosuppression or pregnant employees who refuse a TST. Those who refuse a skin test Foreign-born individuals with a history of BCG vaccination in the past 5 years Those taking systemic steroids in the previous month

Faculty and Student Screening - Faculty/students failing to obtain their annual or semi-annual TST during the month that they are due, are considered non-compliant and will be subject to disciplinary action, up to and including dismissal. Responsibilities Pre-enrollment screening of students is required and must be documented as indicated in student enrollment instructions.

REFERENCES

1. Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, MMWR, 54 (RR17) pp 1-141 December 30, 2005.

2. OSHA Tuberculosis Enforcement Guidelines, October 8, 1993.

3. OSHA Tuberculosis and Respiratory Protection Enforcement, March 24, 2008.

4. Purified Protein Derivative (PPD) - Tuberculin Anergy and HIV Infection: “Guidelines for Anergy Testing and Management of Anergic Persons at Risk of Tuberculosis”, MMWR April 26, 1991; Vol. 40, No. RR-5.

5. Colorado Department of Public Health and Epidemiology, TB division

(www.cdphe.state.co.us/dc/Tbhome.html)

6. Centers for Disease Control, TB Facts for Healthcare Personnel – www.cdc.gov -

Division of Tuberculosis Elimination 7. Guidelines for Environmental Infection Control in Health-Care Facilities –

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), US Department of Health and Human Services, 2003

8. APIC Text Infection Control and Epidemiology, 2nd edition, Association of

Practitioners in Infection Control and Epidemiology, Inc., January 2005

9. Quantiferon® TB-Gold In-Tube Package Insert-www.cellestis.com

TUBERCULOSIS FACT SHEET

Tuberculosis (TB) is a disease that is spread through the air from one person to another. The TB organisms are passed through the air when someone who is infected with active TB of the lungs or throat coughs, speaks, laughs, sings, or sneezes. People near the infected person can breathe the tuberculosis organisms into their lungs.

Colorado reported 103 new cases of active tuberculosis (TB disease) in 2008. This represents a 7.2 percent decrease in the number of cases reported in 2007 (111). The overall case rate in 2008 for TB in Colorado is 2.0 per 100,000, as compared to the overall rate in the United States of 4.2 per 100,000. Of note, the United States TB rate in 2008, was the lowest recorded since national reporting began in 1953. In 2008, the TB rate in foreign-born persons in the United States (20.3 cases per 100,000 persons) was 10 times greater than that of U.S.-born persons (2.0 cases per 100,000 persons). Also of note, 59% of all TB cases in the United States occurred in foreign-born persons in 2008. M. tuberculosis is carried through the air in infectious droplets of one to five microns in size. These droplets are so small that normal air currents keep them airborne and can spread them throughout a room or building. These droplets may be produced when a person infected with active TB coughs, speaks, sings, or spits. In an occupational setting, workers in close contact with persons having infectious tuberculosis are at increased risk for infection. Certain high-hazard medical procedures, which are cough inducing, may further increase the risk for infection of healthcare workers. People with healthy immune systems have the ability to fight off TB after an initial exposure. The following two factors increase a person’s chance of contracting TB:

• Immunosuppression • Frequent exposure to active TB

Usually within 2-12 weeks after initial infection with M. tuberculosis, the immune response limits further multiplication of the tubercle bacilli and immunologic tests for M. tuberculosis infection become positive. However, some bacilli remain in the body and are viable for many years. This condition is referred to as latent TB infection (LTBI). Persons with LTBI are usually asymptomatic (they have no symptoms of TB disease) and are not infectious. Latent TB infection: one is infected with TB, but it has not progressed to active TB. Persons with latent TB infection:

• will have a positive TST (tuberculin skin test) • can take months or years to progress into active TB • may never develop active TB at all

In general, persons with latent TB infection have approximately a 10% risk during their lifetime for the development of active TB. The risk is greatest in the first two years after infection, but some risk persists for decades. People who progress from latent TB infection into pulmonary or laryngeal TB, will have symptoms of prolonged coughing (three or more weeks), fatigue, fever, weight loss, and night sweats. Medication and therapy are available.

Persons with immunocompromising conditions such as HIV, cancer, chemotherapy, drugs (such as prednisone) have a greater risk for the progression of latent TB infection to active disease. The probability that a susceptible person will become infected with M. tuberculosis depends primarily upon the concentration of infectious droplet nuclei in the air, and the duration of exposure. The most important steps in preventing TB transmission are early detection of patients who may have infectious TB; early initiation of Airborne Isolation precautions; and prompt initiation of effective treatment for those in whom the diagnosis of TB is likely. A diagnosis of TB should be considered in any patient with persistent cough (> two weeks duration), or other signs or symptoms compatible with TB such as complaints of bloody sputum, night sweats, weight loss, anorexia, or fever. The probability of TB is higher among patients with a positive TST or a history of a positive TST, previous or recent TB exposure, and among patients who belong to a group at high risk for TB. These high-risk groups include:

• HIV positive patients • other immunosuppressed patients such as chemotherapy patients and patients with

diabetes, silicosis, and/or malnutrition • economically and socially depressed people like the homeless, alcoholics, drug users,

and current or those incarcerated in the past. • people born out of the US in regions where TB is widespread

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Security Management Plan

Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC PURPOSE

The purpose of the Security Management Plan is to define the program to provide a reasonably safe and secure environment for faculty, students, and visitors.

SCOPE

The Security Management Program is designed to assure appropriate, effective response to security situations that could affect the safety of faculty, students, and visitors, or the environment of The Colorado Center for Medical Laboratory Science (CCMLS). The program is also designed to assure compliance with applicable codes and regulations.

The program is applied to 730 Potomac St, Suite 102, Aurora, CO 80011. The security program also applies to all ongoing construction, remodel or department

adjustments or modifications that may be completed throughout the year. FUNDAMENTALS

A. Response plans need to be developed, tested, reviewed and modified as needed to meet ongoing standards and compliance.

B. Security training is an essential part of the safety and security for all CCMLS faculty, students and visitors.

OBJECTIVES

A. The Security Management Plan defines the processes implemented to effectively manage security for faculty, students and visitors within CCMLS.

B. Assess the appropriateness of declaring an area security-sensitive based on the potential for violence or use of weapons; especially vulnerable populations such as the elderly, infants, and children; the availability of drugs, money, and unsecured personal property; identification and access for individuals in all areas of CCMLS.

C. Provide for identification of faculty, students and visitors in the facility. D. Control access to and egress from security sensitive areas, as determined by CCMLS. E. Identify and implement security procedures that address actions taken in the event of a

security incident.

ORGANIZATION AND RESPONSIBILITY A. Hospital Shared Services (HSS), through a contract with HCA HealthONE, provides

security services to the MOB and CCMLS. B. CCMLS Faculty orients new faculty and students to school specific and, as appropriate,

to job-specific security procedures. C. Faculty and students are responsible for learning and following the school security

procedures.

PROCESSES OF THE SECURITY MANAGEMENT PLAN

Security Risk Assessments The MOB Management Company (CBRE) is responsible for initiating a security risk assessments to evaluate potential adverse impact of external environmental services provided on the security of faculty, students and others in the facility, including workplace violence. These risk and vulnerability assessments may include:

• Physical plant size including current and planned changes, type of clientele, volume of business, community setting

• Community crime patterns, neighborhood patterns of change • Exterior lighting, landscaping, communications systems, and parking issues • Security program leadership, policies, procedures, functions, activities, staffing, and

deployment • Physical and electronic security systems Identification Processes Identification name badges must be provided for and worn by all students. Faculty and students are expected to report suspicious activity or individuals to HSS (and/or 911 if appropriate) and/or the MOB Management Company (CBRE). Security Sensitive Areas Access to the CCMLS facility will be restricted and monitored through controls such as identification badges, restricted keys, special lock systems, and visual identification. Regular security rounds in the CCMLS facility are conducted by HSS personnel.

Emergency Security Procedures The MOB Management Company (CBRE) and HSS have provided and approved the use of facility specific operational guidelines for the 730 Potomac St. building. In the event of any security incident, HSS security personnel may:

• Proceed quickly and safely to the scene • Obtain basic information from witness/victim • Request assistance from additional security personnel if needed • Alert others when appropriate • Secure the scene • Direct actions at the scene until relieved by Law Enforcement personnel • Complete required documentation and security incident reports

CCMLS also has procedures related to security response for the following:

• Bomb Threat • Weapons Control • Tornado Plan

Orientation, Training, and Education

All faculty/students must attend new employee orientation within 30 days of hire, or at pre-enrollment orientation, which may include information about safety/security. Faculty/students also receive safety/security training at school orientation.

Ongoing education and training is conducted by CCMLS orientation, training and education as needed.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Bomb Threat Plan Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC A. INITIAL RESPONSE TO BOMB THREAT RECEIVED BY PHONE 1. The individual receiving the bomb threat phone call shall attempt to obtain as much

information as possible regarding the caller as well as the bomb and its location. See Attachment A "Bomb Threat Checklist".

2. Keep caller on line as long as possible. 3. Notify another individual in the facility and/or the MOB Management Company

(CBRE), and/or HSS, they, in turn, shall notify the Aurora Police Department (call 911) and other individuals/departments as appropriate.

4. The Aurora Police Department will determine if, and how, a search shall be conducted and who shall conduct the search.

5. The Aurora Police Department will determine if evacuation of the facility is required, and will supervise the evacuation process.

6. The Aurora Police Department will determine when it is safe for faculty/students to return to the CCMLS facility

BOMB THREAT CHECKLIST Date ______________Facility Name ________________________________________________________ Name & position of person taking call ________________________________________________________ Telephone number that call came in on ____ Time ________________ FILL OUT COMPLETELY IMMEDIATELY AFTER BOMB THREAT 1. When is the bomb set to explode? ____________________________________________________ 2. Where is the bomb located? _________________________________________________________ 3. What does the bomb look like? _______________________________________________________ 4. What type of bomb is it? ____________________________________________________________ 5. What will cause the bomb to explode? _________________________________________________ 6. Did the caller place the bomb? _______________________________________________________ 7. Why did the caller place the bomb? ____________________________________________________ ________________________________________________________________________________ 8. What is the caller's name and address? ________________________________________________ ________________________________________________________________________________ Caller's: Sex _____ Age _____ Race _______________ Length of call _________ DESCRIPTION OF CALLER'S VOICE (Check all that apply) Calm Normal Stutter Disguised Angry Laughing Lisp Accent Excited Crying Raspy Familiar Slow Cracking Deep Rapid Distinct Ragged If voice is familiar, who did it sound like? Loud Slurred Clearing Throat Soft Nasal Deep Breathing _________________________________ BACKGROUND SOUNDS: Street Noises House Noises Factory Office Motors Music Machinery Voices Clear Radio PA System Static Phone Booth Long Distance Animal(s) Other Local Call THREAT LANGUAGE: Well Spoken Foul Taped Incoherent

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Electrical Outage Plan Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC Purpose:

The purpose of the electrical outage plan is to define actions necessary to restore power in the event of an electrical outage. Upon loss of Xcel Energy electrical power to the facility, the backup emergency generators shall restore power to all appropriate circuits.

Plan:

1. Emergency generators shall provide power to appropriate circuits which may include: Alarm systems Egress illumination Illumination of exit signs Reagent, sample, blood storage units in the school

2. If the emergency generator does not appropriately power the reagent, sample and blood storage units in the school (Suite 102), CCMLS will contact the Plant Operations Department at The Medical Center of Aurora (TMCA)

3. The MOB Management Company (CBRE) shall call Xcel Energy to obtain electrical

loss information. CCMLS may also contact Xcel Energy regarding power outage information.

4. CCMLS Program Director will determine whether faculty/students will remain in the

facility until power is restored, or if faculty/students will leave the building to return at a specified time.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Fire Safety Management Plan Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC PURPOSE

The purpose of the Fire Safety Management Plan is to define the program to protect The Colorado Center for Medical Laboratory Science (CCMLS) faculty, students, visitors, etc. from fire and the products of combustion.

SCOPE

The Fire Safety Management Program is designed to assure appropriate, effective response to fire emergency situations that could affect the safety of faculty, students, and visitors, or the environment of CCMLS. The program is also designed to assure compliance with applicable codes and regulations.

The program is applied to 730 Potomac Street, Suite 102, Aurora, CO 80011

The fire safety plan also applies to all ongoing construction, remodel or department adjustments or

modifications that may be completed throughout the year. FUNDAMENTALS

A. The TMCA North Campus MOB buildings must comply with law, regulation, and accreditation, including compliance with the NFPA 101 Life Safety Code®.

B. Deficiencies with these codes must be corrected as quickly as practical. When deficiencies cannot be corrected within a short period of time, Interim Life Safety Measures (ILSM) are considered and implemented whenever individuals are exposed to an increased risk of exposure to fire or products of combustion.

C. The fire alarm, detection and suppression systems must be maintained to ensure reliable performance.

D. Fire safety training is an essential part of fire safety. OBJECTIVES

A. The Fire Plan defines methods for protecting faculty, students, and visitors from the hazards of fire, smoke and other products of combustion.

B. The fire detection and response systems are tested as scheduled, and the results forwarded to the MOB Management Company (CBRE).

C. Summaries of identified problems with fire detection and response systems, and fire response plans, drills and operations, in aggregate, are reported to the MOB Management Company (CBRE).

D. Fire prevention and response training includes the response to fires, at the scene of the fire, and in other locations of the facility, and the use of the fire alarm system, processes for relocation and evacuation of individuals if necessary, and the functions of the building in protection of faculty, students and visitors.

E. The role and use of a fire alarm system (where installed) is included in training.

H. Fire extinguishers are maintained annually, are positioned to be in visible locations, and are selected based on the hazards of the area in which they are installed.

V ORGANIZATION AND RESPONSIBILITY A. The MOB Management Company (CBRE) manages the Fire Safety Management Program. They

identify Life Safety Code deficiencies, develop Plans for Improvement, manage the maintenance of fire systems, the fire plan, and fire response. CCMLS facilitates training of faculty and students. The MOB Management Company and CCMLS monitor fire safety issues, which may necessitate changes to policies, orientation or education, or purchase of equipment.

B. Faculty and students are responsible for learning and following CCMLS fire procedures, including learning and using emergency reporting procedures for fires and fire hazards.

VI PROCESSES OF THE FIRE SAFETY MANAGEMENT PLAN

Fire Safety Management Plan CCMLS has developed and maintains a written management plan describing the processes it implements to effectively manage the fire safety environment of faculty, students and visitors. The management plan is evaluated and modified as necessary, based on changes in conditions, regulations and standards, and identified needs.

Protecting Faculty, Students and Visitors The MOB Management Company (CBRE) and CCMLS manage the program for protecting faculty, students, visitors, and property from fire, smoke, and other products of combustion. The fire safety program includes three phases: 4. The first is design of buildings and spaces to assure compliance with current local, state, and

national building and fire codes. TMCA North Campus MOB contracts with qualified architects and engineers to develop building and fire protections system designs. All designs are reviewed by local or state agencies as a part of the construction and permitting process. A vigorous construction monitoring and building commissioning program round out the design phase.

5. The second phase is maintenance of the current building. The MOB Management Company (CBRE) is responsible for setting maintenance standards based on applicable codes. The standards are applied through a process of planned maintenance and management of the work done by designated contractors to ensure the end product of all work maintains or improves the level of life safety in each affected area.

6. The third phase is an active program of fire prevention, fire safety, and fire response training. Fire Detection and Response System Tests and Inspections The MOB Management Company (CBRE) contracts with a qualified vendor that is responsible for maintenance of the Fire Detection and Response Systems that may include:

• All supervisory signal devices (except valve tamper switches) • All valve tamper switches and water flow devices • All duct detectors, electromechanical releasing devices, heat detectors, manual fire

alarm boxes, and smoke detectors • Occupant alarm notification devices, including all audible devices, speakers, and

visible devices, • Off-premises emergency forces notification transmission equipment • Fire pumps • Main drain tests

• Fire department connections • Fire pumps • Kitchen automatic fire-extinguishing systems • Carbon dioxide and other gaseous automatic fire-extinguishing systems • Portable fire extinguishers • Standpipe systems • Fire and smoke dampers • Automatic smoke-detection shutdown devices for air-handling equipment • Horizontal and vertical sliding and rolling fire doors

Fire Response Plan The Fire Response Plan provides clear, specific instructions for faculty/students responding to an emergency. The procedures provide information about notifying appropriate administrative staff of the emergency and actions to take to protect individual safety. CCMLS is responsible for maintaining copies of emergency procedures in a continuously accessible location. Fire Plan Elements • The roles of all faculty and students at and near the point of fire origin are defined. The basic

plan in the CCMLS facility is based on the acronym “RACE”: Rescue - anyone directly affected by the fire Alarm - by pulling fire alarm pull stations, and calling 4 on the phones Contain - or Close Doors to contain smoke and the products of combustion Extinguish or Evacuate – attempt to extinguish or prepare to relocate individuals

• The roles of all faculty and students away from the point of fire origin are to close doors, and evaluate the situation. If the fire is in horizontally adjacent areas, or areas that are planned to relocate to the area, personnel should focus on where evacuated individuals would be placed.

• If a relocation or evacuation is deemed necessary, faculty and students should assure individuals in the most affected areas are moved first, to adjacent zones.

Processes to Control Flammability of New Acquisitions The MOB Management Company (CBRE) is responsible for assuring fire rated products installed during construction projects meet the standards. Fire-rated products are identified for each project using standard specifications. The MOB Management Company (CBRE) maintains documentation on products installed during each project.

Life Safety Code The MOB Management Company is responsible for complying with codes and standards provided by the Aurora Fire Department. Where significant code violations are identified, they are corrected promptly

Fire Alarm Tests Fire alarm tests are an important tool to maintain the readiness of staff to respond to a fire

emergency. The MOB conducts, and building occupants are requested to participate in annual fire alarm tests.

Maintaining fire-safety equipment and building features

Fire Alarm and Related Systems The MOB Management Company (CBRE) contracts with a qualified vendor who is responsible for maintenance of the fire alarm and related systems, and activities are generally limited to troubleshooting and minor repair. Competent contractors are used to test, inspect, maintain and

repair systems where needed, to assure the special skills and equipment they have are available. Documentation is maintained as part of the MOB database, to assure testing is done in a timely fashion, and to document results.

CCMLS will contract with a qualified vendor who is responsible for annual inspection of fire extinguishers within the school facility.

Interim Life Safety Measures (ILSM) The MOB Management Company(CBRE) is responsible for managing the ILSM program. The program is applied to situations when the assessments of the life safety deficiencies identified in the existing building or occur as part of construction indicate the need. The assessment evaluates the risk of non-compliance with each of the elements of the Unit Concept of the Life Safety Code (i. e., smoke and fire walls, floor separation, exiting, building construction, fire alarm system activity). Where any construction or identified deficiency is identified, the 11 key elements of the ILSM are evaluated, and where applicable to the deficiency or construction activity, compensatory activity is implemented.

Orientation, Training, and Education

All faculty/students must attend new employee orientation within 30 days of hire, or during pre-enrollment orientation.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Fire Response Plan Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC A. Procedures if fire is discovered within The Colorado Center for Medical Laboratory Science (CCMLS) Suite Upon discovery of the fire by faculty, student, volunteer, contract faculty, etc., the following

actions shall be taken utilizing the acronym RACE to outline these actions in an effective, efficient manner:

R escue If a faculty member, student, coworker or visitor is in danger, assist them out

of the area while calling aloud the fire code words, "Code Red" and then location to alert others to the emergency and the need for assistance. Evacuate the shortest distance to safety (down the stairwell if applicable and outside).

A larm Report the fire by calling 911 and providing the following information: building

name (The Medical Center of Aurora North Campus), the building address (730 Potomac Street), the nearest cross street (6th Avenue and I-225), the suite number (102) or exact location of the fire, a call back number (720-449-7450).

Additionally, fire alarm pull stations are located next to the stairwells and in the elevator lobbies on all floors. A fire can be reported by pulling the lever on the fire alarm box all the way down. Notify the MOB Management Company (CBRE) 303-360-3178 or after hours: 303-870-4005

C onfine Close the doors in the fire area. After evacuating appropriate individuals and

upon leaving the fire area, close the door to prevent the spread of smoke and fire.

E xtinguish or Evacuate Attempt to extinguish the fire ONLY under the following conditions: the fire is

small and can be easily extinguished; you are familiar with the operation of an extinguisher and it can be done safely; you have someone with you; you have your back facing an exit. Proceed to the nearest exit to evacuate. Exit via stairwells; do not use elevators. Once outside, move to a safe area away from the building and Fire Department operations.

B. Procedures if fire is discovered outside the CCMLS suite 1. Advise others and move everyone away from the fire 2. Confine the fire by closing all doors in the area; close as many doors as possible between you and

the fire. 3. Report the fire by calling 911 and providing the following information: building name (The Medical Center of Aurora North Campus), the building address (730 Potomac Street), the nearest cross street (6th Avenue and I-225), the suite number (102) or exact location of the fire, a call back number (720-449-7450).

Additionally, fire alarm pull stations are located next to the stairwells and in the elevator lobbies on all floors. A fire can be reported by pulling the lever on the fire alarm box all the way down.

Notify the MOB Management Company (CBRE) 303-360-3178 or after hours: 303-870-4005 4. Feel the door. If it is hot or warm, do not open it. 5. If smoke enters your suite from beneath the door, seal the area with a fire blanket, wet towel or other misted material. If smoke in your suite becomes unbearable, break a window for additional oxygen. 6. If your telephone stops working, display brightly colored material from the window and wave it to make it more visible to rescuers. C. Fire Safety Reminders 1. All faculty/students should be aware of emergency phone numbers. 2. All faculty/students should be aware of fire extinguisher location and operation. 3. In a fire or other emergency, follow the instructions of Emergency Personnel. 4. Do not use the elevators 5. While it is usually advised to go downward in a building during a fire, there are occasions when it may be necessary to go to an upper floor or onto the roof. For example, if smoke enters the stairwell, you may be driven upwards toward cleaner air. 6. If you encounter smoke, get down on your hands and knees. Air is cleaner and cooler near the floor. Crawl to the nearest stairwell and exit if it is safe to do so. D. Fire Prevention Tips 1. Replace any electrical cord that has cracked insulation or a broken connector. 2. Do not pinch electrical cords under or behind equipment/furniture. 3. Do not run electrical extension cords under chair mats or across doorways where they can be stepped on or chaffed. 4. Leave space for air to circulate around heaters and other heat-producing equipment such As refrigerators, computers and copiers. 5. Turn off or unplug all appliances, including coffee makers at the end of each workday. 6. Popcorn is not to be prepared in any of the microwave ovens within the facility. 7. Keep exits, storage areas and stairways free from waste paper, empty boxes, dirty rags And other fire hazards. 8. Remove trash on a regular basis. 9. Close all doors after working hours. 10. Properly store and discard all flammable liquids. 11. Observe the building’s no smoking policies. Never throw matches or cigarette butts into waste containers inside or outside the building.

E. Fire Extinguisher Location & Basic Operation 1. Fire extinguishers are strategically located throughout all buildings according to fire code; faculty/students should be aware of the location of fire extinguishers in the immediate area of CCMLS.

2. All extinguishers in the building may be used on fires originating from wood, paper, plastic, grease, oil and electricity.

3. Operating a fire extinguisher: a. Open the cabinet (if applicable) by turning the handle b. Use the PASS acronym for effective fire extinguisher use: 1. P – pull the safety pin 2. A – aim the hose, nozzle or horn at the base of the fire 3. S – squeeze the trigger handle 4. S – sweep from side to side and watch for re-flash of the fire c. always maintain a three foot clearance area around fire equipment; once the equipment has been used, do not attempt to re-hang it – used fire extinguishers must be serviced immediately.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE WEAPONS CONTROL PLAN

Original: 6/2011 Revised/Reviewed: 3/2021 Prepared by: Sandra DiFalco, MS, MT(ASCP) Approved by: Karen Myers, MA, MT(ASCP)SC PURPOSE: To define a uniform policy for control of weapons that may be brought into the facility SCOPE: All faculty, students, employees, visitors and vendors at the following location: 730 Potomac Street, Suite 102, Aurora, CO 80011. DEFINITION: A weapon is anything that is readily capable of lethal use and possessed under circumstances not appropriate for lawful activity. Colorado Statutory Definition 18-1-901(3)(e) defines a weapon as: firearms, knives, bludgeons, or any other weapon, device, instrument, material or substance whether animate or inanimate which in the manner it is used or intended to be used is capable of causing death or serious bodily injury. The Colorado Center for Medical Laboratory Science (CCMLS) also prohibits the possession of any ammunition for firearms. POLICY STATEMENT: CCMLS does not allow weapons in the facility with the exception of armed security personnel assigned to the facility. In order to ensure a safe environment for faculty, students, employees, visitors and vendors, the carrying or use of any weapon on the premises of CCMLS is prohibited. This weapon prohibition extends to all persons, including persons with approved State of Colorado concealed carry permits and other States handgun permits. Violation of this policy will result in an investigation, possible legal action and/or the appropriate disciplinary action. PROCEDURE:

1. Any incident involving faculty, students, employees, visitors and vendors of all ages in possession of a weapon, as defined by this policy, should be reported to the CCMLS faculty, the MOB Management Company (CBRE) and/or HSS, and/or the Aurora Police Department (911) immediately.

2. If a person is suspected of having a weapon with the intent to harm individuals, or is brandishing the weapon, immediately call 911 and:

a. Evacuate the area and adjacent areas if you are able to do so in a safe manner b. Seek cover/protection for yourself and others behind closed or locked doors. c. Communicate with others about the incident and secure doors in your department

if possible d. Do not negotiate with the person(s) with the weapon or engage in any rescue

attempt. e. Follow instructions from emergency personnel.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Tornado Plan Original: 6/2011 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC

Definition: A violently whirling wind at the earth’s surface, usually but not always marked by a pendant funnel or rope-shaped cloud from an upper general cloud base to and touching the ground. It is invariably associated with a thunderstorm cloud. Tornadoes are most likely to occur in the afternoon, generally between 1:00 P.M. and 9:00 P.M., but may occur at any time. In the Denver area, they usually travel from a southwest to a northeast direction at 25 to 40 miles per hour.

Classification of Alerts: Tornado Watch: An alert issued by the National Weather Service when atmospheric conditions are such that some tornadoes are likely to form in the watch area. A “Watch” means just what it says, “Watch the weather.” Tornado Warning: A warning is issued by the National Weather Service when a tornado has been sighted or detected by radar in the general area and presents a general threat to lives and property in that area. The warning will indicate the location, direction and speed of travel of the tornado. The City of Aurora activates an audible alarm in the event of a tornado warning. In the Event of a Tornado Watch

1. If possible, whomever is made aware of the threatening weather should notify The Colorado Center for Medical Laboratory Science (CCMLS) Program Director, faculty, and students, as well as the MOB Management Company (CBRE).

2. Immediately close blinds in the student laboratory and office suite areas and stay away from the windows.

3. Remain at your normal work station and tune any battery operated radios to a station with weather updates.

4. If possible, remain in the building until the weather has cleared.

In the Event of a Tornado Warning 1. Move away from the perimeter of the building (windowed areas) toward the center of

the building, and close doors behind you. 2. Move towards corridors, stairwells and elevator lobbies. Do not exit these areas or

use elevators. 3. Protect yourself by placing your head close to your knees and covering your neck with

your hands.

4. If anyone has been injured, call 911, assist where possible and follow the Medical Emergency Procedures.

5. If any portion of your facility has been damaged, please notify MOB Management immediately.

THE COLORADO CENTER FOR MEDICAL LABORATORY SCIENCE

Return to F2F Classes – Safer Return Protocol Original: 6/2020 Revised/Reviewed: 3/2021 Prepared By: Sandra DiFalco, MS, MT(ASCP) Approved By: Karen Myers, MA, MT(ASCP)SC Definition: Guidelines have been developed for Faculty and Students during Face to Face (F2F) Teaching in Classroom and Student Laboratory Sessions during the COVID-19 Pandemic. See information below which is also published in the Student Policy Manual, #3.10. Overview: Our mission is to educate students according to the requirements in the professional field which include as a major portion of the curriculum the development and practice of face-to-face laboratory skills initially in a teaching laboratory setting and later in a clinical setting. The student laboratory teaching courses are required for and pre-requisite to clinical course work which is scheduled during the spring semester. The goal of the protocols herein is to provide a safe educational environment for our students, our faculty, and for their families. These protective measures are a requirement for all CCMLS faculty and students. We cannot provide safe practices without cooperation and participation of all students and faculty. Under the “Third updated amended Public Health Order pursuant to the Governor’s directive Order D 2020 017 post-secondary institutions, including private and public colleges and universities, for the purpose of …providing in person classroom or laboratory education for [no more than]10 students [inclusive of instructor] per classroom or lab in medical training fields…providing social distancing requirements are observed”, the Colorado Center for Medical Laboratory Science (CCMLS), a program of Metropolitan State University of Denver (MSU Denver). requests to resume face-to face laboratory classes for its medical professional program in medical laboratory science. Lectures and on-line learning activities will commence June 1, 2021, via Canvas and MS teams. Face-to-face laboratory classes will begin June 15, 2021, in accordance with the guidelines herein. Educational practices of CCMLS shall follow, but are not limited to, Colorado state public health and national regulations adhered to by Metropolitan State University of Colorado (MSU Denver), the Colorado Department of Public Health and Environment (CDPHE), Colorado proclamations issued by governor Gerald Polis, the Colorado Department of Higher Education (CDHE), the Center for Disease Control (CDC), and best practices within the clinical laboratory field. Schedule of Courses and Delivery Mode Until further notice, minimally through the summer semester, CCMLS faculty will deliver to all students enrolled in the 2021-2022 academic: 1. required course pre-modules on-line June 1 – June 14, 2021 through the Canvas system. Students should contact course instructors with questions after reviewing the pre-modules in the Canvas learning system. These are self-paced modules that should be completed by deadlines as indicated within Canvas course materials for: a. MLAB401: Clinical Lab Skills Instructor:

Karen Myers kmyers29@msudenver.edu b. MLAB421: Urinalysis Instructor: Parker Wilson pwilso38@msudenver.edu 2. the CCMLS required student orientation session on Wednesday June 19, 2021, from 9:00a to 5:00pm through MS Teams. 3. summer semester courses as represented in the “Summer Semester CCMLS Lecture and Student Laboratory” schedule (posted on the CCMLS Website and Canvas Student Organization). Course materials are located on the Canvas system. Summer and fall semester courses will be delivered in hybrid format. i. Lecture session will be through MS Teams ii. Laboratory Sessions: Each class member will be assigned to either Lab Group 1 or Lab Group 2 and will attend face to face lab sessions, with a number of other class members, in compliance with distancing and PPE guidelines during a 3-4 hour lab session. Instructions on required distancing guidelines and PPE will be posted on the Canvas Student Organization and discussed during the June 9, 2021 orientation. See guidelines, this policy, pp. 3-5. 4. Further instructions regarding regulations for fall semester classes will be provided to class members no later than July 15, 2021. Required MS Teams Delivery System 1. It is an expectation that prior to the CCMLS orientation that all CCMLS students will have access to the MS Teams app through MSU Denver (students also have access to the entirety of the Office 365 Suite if desired). If there are questions regarding access to MS Teams, contact the IT Department at MSU Denver at: email support@msudenver.edu; phone: 303-352-7548; URL to submit a ticket: https://www.msudenver.edu/technology/helpdesk/ Students must have a 900# ready when contact with IT services is made. 2. Explore prior to June 9th orientation the basic functionality (viewing the calendar for lectures, knowing how to join a “meeting” when the lecture is ready to begin (or the orientation on June 9th). Faculty will give additional instructions after that point. 3. Each student will be able to log into Teams using their MSU Denver email and password. 4. It is an expectation that students will have a working web-camera and microphone (built into the computer or external). Faculty expect to see and hear from class members during lectures). Guidelines for CCMLS Faculty and Students During Face-to-Face Teaching Guidelines are from the state CDPHE and CDC recommendations, or are based on best practices in clinical laboratories within healthcare organizations in Colorado. Required PPE in all Face-to-Face Settings C = classroom L= Lab The following PPE will be worn at all times, as indicted by “C” or “L”, by both faculty and students in both classroom and laboratory settings. 1. Face masks/coverings – these need to be changed out daily (C, L) 2. Safety glasses (L) – these must be disinfected and kept in station drawers in between labs. 3. Lab Coats (L) – follow protocol for storage as demonstrated during safety orientation 4. Gloves (L) General Hygiene Requirements: 1. All students and faculty should self-screen daily using the protocol below. 2. Enter the facility with a face mask or face shield that covers the nose and mouth. (https://covid19.colorado.gov/mask-guidance) 3. Individuals entering the facility will be temperature screened in the lobby by healthcare personnel. An individual who does not pass the temperature screen will be sent home. Faculty and students should call per department protocol if they fail temperature screening. 4. Class size in the CCMLS classroom setting and/or the student laboratory is limited to no more than 10 individuals inclusive of the instructor(s) at any given time.

5. Students and faculty must maintain a 6-foot social distancing. 6. Students should bring to classes only those instructional materials needed for the current class session. Any coats must be left on the coat hangers in the classroom. Extra personal belonging should be kept to a minimum and stored on shelving for that purpose designated by faculty in order to avoid placing personal belongings on common areas. 7. All areas in use during a teaching session must be wiped down with appropriate disinfectant and paper towels. 8. No lingering in common area spaces 9. No food-based events or gatherings allowed. 10. It is recommended that elevator use follow the guidelines posted; if using stairs, physical distancing must be maintained. Self-Screen Protocol: By accessing the MSU Denver-CCMLS facilities each individual has confirmed they have none of these symptoms and will comply with safe return protocols and expectations. If you are not feeling well or answer “Y” to any of the following you are not allowed on campus until you are symptom free for 24 hours. SYMPTOMS – Self Assessment YES/NO; Fever or Elevated Body Temperature Y / N; Cough Y / N; Shortness of Breath or Difficulty Breathing Y / N; Headaches/Body Aches/Muscle Aches Y / N; Sore Throat Y / N; Nausea/Vomiting/Diarrhea Y / N; Loss of Taste or Smell Y / N; Chills and Repeated Shaking with Chills Y / N; In the last 14 days, have you been in contact with a person with known COVID-19 Y / N Classroom Specific Hygiene Requirements: While CCMLS classes and other learning activities will be delivered on-line via BlackBoard learn and MS Teams during the summer semester, and possibly also during the fall semester, the following guidelines apply to faculty and students once regulations allow for face-to-face classroom sessions. 1. Allow time for hospital pre-screening before reporting to assigned classes. 2. Gathering outside classroom, social or otherwise, is prohibited. 3. Report to class at the time designated by faculty who will be present to open classroom doors for students. 4. CCMLS classroom will be posted with signage on appropriate hand-washing hygiene and other applicable safety measures. 5. Hands should be washed with soap and water or appropriate hand sanitizer for 20 seconds upon entering the classroom and before leaving the classroom. 6. Wear masks/face-covering at all times and remain 6 feet apart from one another. 7. Classroom tables and classroom common areas, including door knobs and light switches, must be disinfected at the end of any classroom session using disinfectant approved by the EPA for SARSCoV-2. Student Laboratory Specific Hygiene Requirements: 1. Allow time for hospital pre-screening before reporting to assigned classes. 2. Gathering outside the student laboratory, social or otherwise, is prohibited. 3. Report to the student laboratory at the time designated by faculty who will be present to open the laboratory classroom doors for students.

4. CCMLS student laboratory will be posted with signage on appropriate hand-washing hygiene and other applicable safety measures. 5. Hands should be washed with soap and water or appropriate hand sanitizer for 20 seconds upon entering the student laboratory and before leaving the laboratory classroom. 6. Wear masks/face-covering at all times and remain 6 feet apart from one another. 7. When using common shared equipment, do not congregate together. Instead use appropriate social distancing and remain 6 feet apart from one another. 8. Wear a lab coat after hand-washing and when in the student laboratory at all times. 9. Wear safety glasses/face shield in the student laboratory at all times. 10. Wear gloves as directed by the laboratory faculty. When wearing gloves, remember that gloves are considered “contaminated”. Do not touch face, nose, and eyes with gloved hands. Do not wear gloves into non-laboratory areas. 11. When using common shared equipment, do not congregate together. Instead use appropriate social distancing and remain 6 feet apart from one another. 12. At the end of your lab session, using disinfectant approved by the EPA for SARS-CoV-2, a. disinfect your lab station, lab cabinet handles, lab common areas and your lab chair. b. Wipe off light switches and door handles during the disinfection process. c. If the computer keyboard in a lab pod area has been utilized, make sure it is disinfected with alcohol preps of the appropriate concentration. 13. Remove lab coats and store coats according to protocol demonstrated during safety orientation. 14. Remove gloves according to protocol demonstrated during safety orientation. 15. Wash your hands with soap and/or designated hand sanitizer and water for 20 seconds immediately after taking off gloves and right before leaving laboratory area. References: CCMLS Safety Manual and Orientation Materials, 2021. CDPHE. Guidance for Institutions of Higher Education, April 28, 2020. https://highered.colorado.gov/staying-informed-about-coronavirus-disease-covid-19 CDPHE. Third Updated Public Health Order 20-24, April 1, 2020 CDPHE. Amended Public health Order 20-28 Safer at Home. May 4, 2020. CDPHE Website. Prevent the Spread of COVID-19. https://covid19.colorado.gov/prevention CDPHE Website. Safer at Home – Higher Education. https://covid19.colorado.gov/safer-athome/safer-at-home-higher-education Jared Polis, Executive Order D2020 017, March 26, 2020 Jared Polis, Executive Order D 2020039, April 17, 2020. https://drive.google.com/file/d/1fD1xqzAhwzRmiC8FnYEJYDdvnvp6vF4I/view Lorince, Sharon. June 2020, Department of Facilities Management, Metropolitan State University of Denver. Personal Communications. slorince@msudenver.edu Walton Zajdowicz, Sheryl, May, 2020. Department of Biology. Metropolitan State University of Denver. Personal Communications. swaltonz@msudenver.edu.