Clinical Safety Program - Environment, Health and Safety

The clinical safety program at UNC-Chapel Hill is designed to promote environments that are free of hazards specifically found in the clinical environments. Clinical environments, especially those in health care facilities, receive clinical specimens with requests for a variety of diagnostic and clinical support services. Typically, the infectious nature of clinical material is unknown, and specimens are often submitted with a broad request for microbiological examination for multiple agents. These areas require special attention to hazards to protect both the employees and the patients.

Attendance at an Environment, Health and Safety office bloodborne pathogens training session or taking the class online is required of all new employees occupationally exposed to blood or other potentially infectious materials. New clinic employees will receive bloodborne pathogens training as a part of the Clinic Environment Orientation. Other new employees with occupational exposure should attend one of the training sessions or take the class online. Annual training updates can be fulfilled by attending one of the sessions or by completing the bloodborne pathogens online training course.

Training Schedules

The Needlestick Safety and Prevention Act directed OSHA to revise the Bloodborne Pathogens standard to include new examples in the definition of engineering controls along with two new definitions; to require that Exposure Control Plans reflect how employers implement new developments in control technology; to require employers to solicit input from employees responsible for direct patient care in the identification, evaluation, and selection of engineering and work practice controls; and to require certain employers to establish and maintain a log of percutaneous injuries from contaminated sharps.

All University employees who serve as medical staff or other clinic personnel (in a temporary, part-time or full-time capacity) must complete all required medical surveillance and safety training modules in accordance with University Policy and OSHA, Joint Commission (formerly JCAHO), EPA, or other regulations. For further information about requirements, please go to the condition of employment chart for healthcare workers.

New Staff Safety Orientation Requirements

Remember, these are the orientation requirements for new staff. The New Employee Clinic Orientation online training course includes a number of topics, including bloodborne pathogens and tuberculosis. You must complete all the training modules and pass the post-test. You also are required to contact the UEOHC at 919-966-9119 to schedule an immunization review. This must be completed within the first 45 days of employment.

Existing Clinical Staff Annual Requirements

Remember, these are the annual requirements for existing clinical staff.

General Requirements

Bloodborne Pathogens Online Training Course
Annual training requirement. Required of staff who may be exposed to blood or body fluids.
Joint Commission and Emergency Preparedness Refresher for the Clinic Environment Online Training Course
Annual training requirement. Required of all clinical staff.
Tuberculosis and Infection Control Online Training Course
Annual training requirement. Required of all clinical staff. Information regarding Tuberculosis surveillance programs can be found on the immunizations page.

Special Requirements for those who have been told they are in the Respiratory Protection Program

Respiratory Protection for Tuberculosis and Infectious Disease Online Training Course
If you have been told your job requires the use of respiratory protection, then annual fit-testing and training are required. Follow the link to the online training and complete the post-test. Also, contact UEOHC at 919-966-9119 to schedule fit-testing.

Employee Safety Training Record

Review or print your current safety record by logging into the EHS compliance portal. Note that you will need your PID.

Where do I have to go to have my TB skin test and Immunization review completed?: Employees need to go to the University Employee Occupational Health Clinic to complete these requirements. If an employee has these records from some other source they may be fazed to 919-966-6337.
I work in Healthcare Facility. Which new employee orientation do I need to attend?: If you are classified as working in a healthcare facility, then you need to attend the new employee orientation for the clinic environment. Orientation schedules can be found at the training schedule page or, you can elect to take this training online.
Do I need to complete annual refreshers of training and immunizations?: If you are classified as working in a clinic environment, you are required to complete annual training for Joint Commission (formerly JCAHO) and Tuberculosis. If you are classified as being exposed to blood, then you must also complete the Bloodborne Pathogen training on an annual basis. If you are working in a healthcare facility, you are also required to have a TB skin test on an annual basis. The immunization review process is a one-time requirement.
How am I notified when my annual TB screening is due?: You will receive a reminder telling you what things you need to complete to be in compliance. You also have a departmental representative who receives a composite monthly report.
If I am injured on the job, what type of protocol needs to be followed?: Please refer to the Workers’ Compensation pages for more details.

Policies and Training

Associated Departments:

Workplace Safety