Section 1000: Campus Policy

Effective: January 1, 1996

Purpose and Objectives

The purpose of this policy is to establish a comprehensive Exposure Control Policy which establishes requirements for protection against communicable diseases and infection for the campus community and the public it serves. MSU-Northern recognizes that exposure to communicable diseases is an occupational health hazard and that communicable disease transmission is possible during day-to-day activities. While each individual is ultimately responsible for his or her own health, MSU-Northern recognizes a responsibility to provide a safe work place.


  • To provide protection from communicable diseases to the staff, faculty and students.
  • To provide services to the public without regard to known or suspected diagnoses of communicable disease in any person.
  • To regard all patient contacts as potentially infectious.
  • To provide training and personal protective equipment (PPE) needed for protection from communicable diseases.
  • To recommend current vaccinations for all individuals.
  • To encourage participation in available counseling services.
  • To prohibit discrimination for health reasons.
  • To regard all medical information as strictly confidential. No individual's health information will be released without the signed written consent of the individual.


  • The MSU-Northern Safety Committee will provide oversight of this policy and its implementation. Semi-annually the Safety Committee will review the implementation of this policy. The proceedings must be recorded and published.
  • It is the responsibility of supervisors at all levels to arrange for implementation of an exposure control program.
  • The Director of Student Health Services is appointed Infection Control Officer and has oversight responsibility for implementation of MSU-Northern's Exposure Control Program at all levels throughout the University. Specifically:
    1. Investigate all incidents of known or suspected exposure to an infectious material.
    2. Evaluate possible exposures to communicable diseases and coordinate communications between the campus and the county health department.
    3. Collect quality assurance data on the campus infection control program and present these data to the safety committee at regular meetings.
    4. Conduct spot inspections of campus operations to ensure compliance with this policy.
    5. Maintain a confidential database of exposures and treatment given.
    6. Coordinate the immunization program.
    7. Develop criteria for purchase of infection control personal protective equipment and determine location and stocking levels for each activity on campus.
    8. Notify the campus Safety Officer if quality assurance data indicate a safety hazard requiring immediate attention.
    9. Provide technical assistance in development of infection control educational programs.
    10. Serve as the "designated officer" as required by the Ryan White Comprehensive Resources Act of 1990.
  • The Training Officer will direct development and delivery of a comprehensive infection control educational program which complies with OSHA regulation 29 CFR Part 1910.1030.
  • Heads of Academic and Staff Departments will make arrangements to have the training presented.

Exposure Determination

  • The following job classifications are reasonably anticipated to involve exposure to blood, body fluids, or other potentially infectious substances in the performance of their duties:
    1. Student Health Service Nurse
    2. Athletic Trainer
    3. Facility Custodians
    4. Child Care Providers
    5. Laboratory Instructors and Monitors
    6. Residence Hall Assistants and Monitors
  • The following tasks are reasonably anticipated to involve exposure to blood, body fluids, or other potentially infectious materials:
    1. Provisions of emergency medical care to injured or ill patients;
    2. Routine care of patients in recognized treatment facilities;
    3. Cleaning residence halls and other campus facilities, especially rest room facilities;
    4. Supervising Residence Halls;
    5. Monitoring and teaching various laboratory activities;
    6. Providing Child Care at the Campus Child Care Facility.

Exposure Prevention and Control

  • Communicable disease control is best accomplished with comprehensive preventive measures. These measures encompass employee and student training, extensive communications such as newsletters and flyers, screening, and prompt reporting of known or suspected exposure incidents.
  • A known or suspected exposure incident must be fully investigated to minimize any subsequent exposure.

Employee Training

Supervisors at all levels must provide notice of the likelihood of exposure to all employees upon commencement of employment and annually thereafter. Furthermore, supervisors must arrange for exposure prevention and minimization training to all employees upon commencement of employment and annually thereafter.

The Director of Student Health Services and the University Wellness Director will assist supervisors in developing training programs.

Training will be accomplished in compliance with OSHA regulation 29 CFR Part 1910.1030 and shall include:

  • An accessible copy of 29 CFR Part 1910.1030 and an explanation of its contents.
  • An explanation of the University exposure control policy.
  • A general explanation of the causes, symptoms, and transmission of infectious diseases.
  • An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to potentially infectious substances.
  • Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment.
  • Information on preventive measures.
  • Information on post-exposure protocol.
  • Information on the signs and color-coding required for biohazard materials and on their proper storage and disposal.

Health Maintenance

Work restrictions for reasons of infection control may be initiated by the Department Chair/Supervisor or the Infection Control Officer. These may be temporary or permanent. As an example, individuals with extensive dermatitis or open skin lesions on exposed areas may be restricted from providing patient care or performing duties that would cause unnecessary exposure to body fluids.

All individuals are encouraged to receive annual health evaluations and are encouraged to be immunized against hepatitis B (HBV), influenza, measles, mumps, rubella, tetanus, and diphtheria. Employees of the Montana State University system are able to receive these immunizations as a benefit of their insurance coverage.

The Infection Control Officer will maintain records in accordance with OSHA's CFR 29, Part 1910.1030.

  • Individual participation in the infection control Program will be documented, including:
    1. Name and SSN of the individual.
    2. Immunization records.
    3. Circumstances of exposure to communicable diseases.
    4. Post-exposure medical evaluation, treatment, and follow-up.
    5. Dates and content of training.
  • Infection control records will become part of the individual's health file and will be maintained for the duration of employment plus 30 years.
  • Medical records are strictly confidential. Medical records will be maintained in the office of the Infection Control Officer. Medical records will not be released without the written consent of the individual. There will be no exceptions to this policy for University Administration, State Administration, or insurance companies.
  • Records of participation in available counseling programs are considered medical records.
  • Individuals may examine their own medical records, and may request that copies be sent to their personal physician. Release of medical records to another physician will be made only with the consent of the individual.
  • Abstracts of medical records without personal identifiers may be made for quality assurance, compliance monitoring, or program evaluation purposes as long as the identity of individuals cannot be determined from the abstract.

Personal Protective Equipment

Specification, purchase, storage, and issue of Personal Protective Equipment (PPE):

  • The University is responsible to supply, repair, replace, and dispose of PPE.
  • Standards for PPE will be developed by the Infection Control Officer and the Safety Committee, and updated or modified as needed.
  • The Infection Control Officer will assist each department head in determining proper stock levels of PPE for each department.
  • The department head will ensure that stock of PPE is adequate and that replacements are acquired in a timely manner before stocks are depleted.
  • The location of PPE will be posted and accessible to department members at all times.
  • Available PPE will include disposable gloves, a barrier type mask with a one-way valve for rescue breathing/CPR, rubber gloves for disinfection, leak proof disposal bags, and sharps containers if applicable.
  • Disposable gloves will be latex.
  • Sharps containers will be closable, puncture resistant, and leak proof Sharps containers will be color-coded, labeled as a biohazard, and immediately accessible.

Selection and Use of Personal Protective Equipment

No emergency is predictable or controllable. While blood is the single most likely source of HIV and HBV infection in the work place, it is safest to assume that all body fluids are infectious. For this reason, PPE will be chosen to provide barrier protection against all body fluids.

Disposable latex gloves will be worn during any patient contact when the potential exists for contact with blood, body fluids, non-intact skin, or other infectious material. Gloves will be replaced as soon as possible when soiled, torn, or punctured. Wash hands after glove removal. Disposable latex gloves will not be reused or washed and disinfected for reuse. Where possible, gloves should be changed between patients in multiple injury situations.

Post-Exposure Protocols

  • Any individual exposed to potentially infectious material will immediately wash the exposed area with soap and water or saline eye wash if the eyes are involved.
  • Any individual having an occupational infectious disease exposure will immediately report the exposure to the supervisor or the Infection Control Officer.
  • The individual will fill out an employee injury report. Report forms are available from each department chair/supervisor or the Infection Control Officer. The individual will fill out an employee injury report within 24 hours for any of the following exposures:
    1. Needlestick injury.
    2. Break in skin by a potentially contaminated object.
    3. Splash o f blood or other potentially infectious material onto eyes, mucous membranes, or non-intact skin.
    4. Mouth-to-mouth resuscitation without pocket mask or one-way valve.
    5. Other exposure that an individual may feel is significant.
  • The report will include details of the task being performed, the probable means of transmission, the portal of entry, and the type of PPE used. The report will be forwarded to the Infection Control Officer.
  • The Infection Control Officer will evaluate the report for exposure hazards. If a possible exposure has occurred, medical evaluation by a physician will be arranged by the Infection Control Officer within 48 hours after exposure. If no exposure occurred, the Infection Control Officer will counsel the member on exposure hazards. The Infection Control Officer will complete the injury report, indicating disposition of medical management, and file the report with the appropriate individuals.
  • The Infection Control Officer will perform or refer individuals for infection control retraining or for stress management counseling if indicated.
  • The source patient will be traced to the receiving medical facility by the Infection Control Officer. The infection Control Officer will notify the receiving facility that a probable communicable disease exposure occurred, and request an infectious disease determination, as provided under the Ryan White Act of 1990.
  • Request consent to test the source patient for HIV and HBV will be made. The source patient has the right to refuse such testing.
  • The Safety Officer will assume the duties of the Infection Control Officer during absence except for those duties which require specialized professional training and education.

Compliance and Quality Monitoring and Program Evaluation

Compliance and quality monitoring

  • The Infection control Officer will collect compliance and quality monitoring data including:
    • Inspection of campus facilities.
    • Observation of campus activities.
    • Analysis of reported exposures to communicable diseases.
  • A bi-annual quality and compliance report will be made by the Infection Control Officer to the Safety Committee.

Program Evaluation

  • The Infection Control Program will be re-evaluated at least semi-annually by the Safety Committee to ensure that the program is appropriate and effective.
  • In addition, the Infection Control Program will be re-evaluated as needed to reflect any significant changes in assigned tasks or procedures; in medical knowledge related to infection control; or in regulatory matters.