SWIFS Environmental Health and Safety Program v2.0 (01.23.2008) 58 Pages

8/2/2019 SWIFS Environmental Health and Safety Program v2.0 (01.23.2008) 58 Pages

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Dallas County Southwestern Institute of Forensic Sciences

ENVIRONMENTAL HEALTH AND SAFETY PROGRAM

Version 2.0

Authorized by: Jeffrey J. Barnard, M.D., Director and Chief Medical Examiner

Effective Date: January 23, 2008

This is an uncontrolled copy of a controlled document.


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Dallas County Institute of Forensic Sciences

EHS Manual

Summary of Changes from Previous Manual Version

Previous Version: EHS Manual, version 1.0Current Version: EHS Manual, version 2.x

1. Entire document Typographical and grammatical errors were corrected and the documentwas moved to an electronic format.

2. Overview EHS Program Section was reorganized and responsibilities of EmergencyWardens was added.

3. Facility Emergency Response Facility Lock Down and Staff Accountability During Non-Standard Work Hours were formally added to the manual. Expanded instructions forEmergency Wardens were added to EHS Resource Documents.

4. General Safety Procedures Minor revisions were made to the section on handling firearms.5.

Biological Exposure Control The section was significantly reorganized and redundantinformation was removed. Expanded instructions for use of PPE were added to EHS

Resource Documents. PPE requirements for the Medicolegal Death Investigators and

Autopsy staff were revised based upon job duties and procedural changes. Job titles wereupdated in the section identifying occupationally exposed staff. A section regarding

occupational exposure testing for tuberculosis was added. Instructions were improved for

diluting bleach.

6. Chemical Safety Plan Components of the Dallas County Hazardous Chemical SafetyTraining Manual were incorporated into the plan where applicable; the County document is

no longer used.7. Radiation Safety Plan Current UT-Southwestern radiation procedures were added to the

EHS Resource Documents.

8. Smoking Policy This section was moved from the IFS Security Manual to the EHS Manual.9. Reporting Injuries and Exposures This section received minor revision reflecting changes

in County policy.

10.EHS Audits and Inspections This section received minor revision.

Dallas County Institute of Forensic Sciences 1 Summary of Changes

Environmental Health and Safety Program Version 2.0



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EHS Manual Revisions and Corrections, Version 2.x

Date Description Approval

Dallas County Institute of Forensic Sciences 1 Revisions and Corrections

Environmental Health and Safety Program Version 2.x



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Dallas County Institute of Forensic Sciences 1 EHS Program Overview



Environmental Health and Safety (EHS) Program

OVERVIEW

1.Policy Statement1.1.It is the goal of the Dallas County Institute of Forensic Sciences to provide a safe and

healthy workplace for employees and visitors.

1.2.Per Dallas County policy, working safely is a condition of employment.1.3.No employee is required to work at a job he or she knows is not safe or healthful.1.4.The nature of work performed at forensic facilities inherently offers a variety of potential

risks from biological, chemical, electrical, ergonomic, radiological, and other hazardsroutinely found in the workplace.

1.4.1.Therefore, safe and healthy work practices must be routinely incorporated as a part ofevery process and procedure.1.4.2.All employees must constantly be aware of conditions in work areas that can produceinjuries and/or illness and act accordingly.

1.4.3.The cooperation of each employee is critical in detecting hazards and, in turn,controlling them.

1.4.4.Employees must immediately inform supervisors, the EHS Manager or Deputy, theEHS Committee (in writing), or the Director of any EHS situation beyond their ability

or authority to correct.1.5.It is the intent of the Institute to conform to industry-standard environmental, health, and

safety practices through adherence to standards developed by the National Association ofMedical Examiners (NAME) and the American Society of Crime Lab Directors

(ASCLD).

1.6.It is the intent of the Institute to comply with applicable environmental, health, and safetyregulations such as Texas Commission on Environmental Quality (TCEQ) biological and

hazardous waste disposal regulations and Texas Department of State Health Services

(DSHS) regulations including Control of Radiation, Bloodborne Pathogen Control, TexasHazard Communication Act, etc.

1.7.To implement and oversee these environmental, health, and safety goals, the Institute hasdeveloped a written EHS Program, designated an EHS Manager and Deputy Manager, andestablished an EHS Committee.

1.8.Environmental, health, and safety concerns should be directed to your supervisor, theDirector, the EHS Manager or Deputy, or in writing to the EHS Committee.

2.Objectives of the EHS Program2.1.The objectives of the Dallas County Institute of Forensic Sciences Environmental Health

and Safety Program are to



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2.1.1.Provide a safe and healthy workplace for employees and visitors2.1.2.Advise employees of safe and healthy work practices which must be followed2.1.3.Advise employees of regulatory requirements2.1.4.Conform to industry-standard health and safety practices

3.EHS Committee, Manager, and Deputy Manager

3.1.The Director will appoint an EHS Manager and members of the EHS Committee.3.2.The EHS Manager will appoint a Deputy Manager.3.3.Membership of the EHS Committee will provide representation from each functional

unit and include a mixture of supervisory and non-supervisory personnel, the EHSManager, EHS Deputy Manager, Lead Emergency Warden, and the Director or his

designee.

3.4.The EHS Committee will meet as needed; quarterly meetings are encouraged.3.5.The EHS Committee will serve as the Biological Exposure Control Committee.3.6.Minutes of EHS Committee meetings will be taken.

4.Emergency Wardens4.1.Emergency Wardens lead and direct staff response to the Facility Emergency Response

Plan under the direction of the Deputy EHS Manager who serves as the Lead Warden.

4.1.1.The Assistant Lead Wardens are the Chief Field Agent and the Deputy FieldAgent.

4.2.Wardens are staff volunteers who are trained to assist and account for staff during afacility emergency.

4.2.1.There are typically a minimum of two emergency wardens per floor.5.Components of the EHS Program

5.1.The following programs are included in this Environmental Health and Safety Program:5.1.1.Facility Emergency Response Plan5.1.2.Safe Operating Procedures5.1.3.Biological Exposure Control Plan5.1.4.IFS Chemical Safety Plan5.1.5.IFS Radiation Safety Program5.1.6.Workplace Exposure and Injury Reporting5.1.7.Quarterly Safety Inspections and Annual Safety Audit

6.Program Responsibilities6.1.Employees have the responsibility to work safely and to

6.1.1.Follow environmental, health, and safety procedures outlined in this Program,communicated by your supervisor, received in training, and/or known to you based

upon your education, experience, and training.



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6.1.2.Use, store, and dispose of chemicals safely.6.1.3.Use, store, and dispose of biologicals safely.6.1.4.Use x-ray equipment safely.6.1.5.Use proper and safe techniques, standard operating procedures, good personal

hygiene, and personal protective equipment (PPE).

6.1.6.Take responsibility for learning and knowing the environmental, health, and safetyhazards associated with chemicals, biologicals, instrumentation/equipment, and

procedures used in your work area.

6.1.7.Diligently identify unsafe and/or unhealthy conditions within the workplace;immediately correct and/or report unsafe or unhealthy conditions to your Supervisor,

the Director, EHS Manager or Deputy, and/or EHS Committee.6.1.8.Be prepared to act appropriately in an emergency situation.6.1.9.Report suspected workplace exposures timely and seek medical treatment as

needed.6.1.10.Advise supervisors if additional personal protective equipment or other safety

equipment is indicated.

6.1.11.Attend initial and annual environmental, health, and safety training sessions.6.1.12.Know the location and effective use of safety showers, eyewash stations, first aid

kits, fire extinguishers, MSDSs, etc.

6.1.13.Know your floor emergency wardens.6.1.14.Provide written inquiry to the EHS Committee as needed to resolve

environmental, health, and/or safety related concerns.

6.1.15.Forward MSDSs received with merchandise to the EHS Deputy Manger.6.1.16.Participate in exercises and drills of this Program.6.1.17.Drive safely at all times. Follow Dallas County policies and procedures located

in each County vehicle including the immediate reporting of all accidents.6.2.Supervisors have the responsibility to

6.2.1.Support and implement the EHS Program.6.2.2.Communicate procedural or laboratory-specific environmental, health, and safety

information to employees.

6.2.3.Ensure that employees receive initial and follow-up environmental, health, andsafety training as applicable.

6.2.4.Oversee occupational exposure reporting and exposure monitoring including leadtesting, hepatitis vaccination, workers compensation reporting, etc.

6.2.5.Immediately correct and/or report unsafe or unhealthy conditions to the Directorand/or EHS Manager or Deputy.

6.2.6.Support and participate in the EHS Committee.6.2.7.Receive and respond to requests for personal protective equipment and other safety

equipment.6.2.8.Take appropriate supervisory and/or disciplinary action when safety rules are

violated.

6.3.EHS Manager reports to the Director for issues related to environmental, health, andsafety and has primary responsibility for oversight of the EHS Program including but not

limited to



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6.3.1.1.Maintaining and updating the EHS Program and reviewing annually.6.3.1.2.Monitoring laboratory practices to verify continuing compliance with policies

and procedures.

6.3.1.3.Performing quarterly environmental, health, and safety inspections.6.3.1.4.Scheduling, coordinating, and overseeing an annual EHS Audit of the

Institute EHS Program and drills or exercises of the Plan.6.3.1.5.Maintaining applicable records.6.3.1.6.Investigating EHS issues, proposing corrective action as applicable to Section

Chief, Executive Committee, and/or EHS Committee, and verifying

implementation of corrective action.

6.3.1.7.Proposing corrections and improvements in the EHS Program.6.3.1.8.Overseeing generation of annual Chemical Inventory List and filing Texas

Tier Two forms as applicable and maintaining documentation as required.

6.3.1.9.Maintaining and distributing Material Safety Data Sheets (MSDSs).6.3.1.10.Making MSDSs available to applicable staff upon request.6.3.1.11.Overseeing biological and hazardous waste disposal for the Institute and

filing annual waste summaries as applicable.6.3.1.12.Keeping abreast of changes in laws and regulations applicable to theInstitutes EHS Program.

6.3.1.13.Organizing and overseeing meetings of the EHS Committee and generatingmeeting minutes.

6.3.1.14.Overseeing the IFS Radiation Safety Program and interfacing with UT-Southwestern Radiation Safety.

6.3.1.15.Overseeing occupational exposure testing for lead, formaldehyde, etc.6.3.1.16.Overseeing safety related training including first aid, CPR, fire extinguisher

use, etc.6.4.EHS Committee (Biological Exposure Control Committee) has responsibility to

6.4.1.Maintain current awareness of the EHS Program, diligently implement the Programwithin IFS, and resolve or refer potentially unsafe conditions for review.

6.4.2.Serve as a liaison for each IFS functional unit as it relates to flow ofenvironmental, health and safety issues and information.

6.4.3.Participate in EHS audits as applicable, review results of audits, and recommendchanges in the EHS Program as applicable.

6.4.4.Investigate and respond to EHS concerns brought to the attention of theCommittee; both the request and the response should usually be in writing.

6.4.5.Review and recommend changes in environmental, health, and safety practicesincluding use of personal protective equipment and the EHS Program.

6.4.6.Review use of sharps and make recommendations to move to engineered sharpsproducts as appropriate.

6.4.7.Address issues brought to the attention of the Committee.6.4.8.Assist in implementing new EHS programs.

6.5.Director has the responsibility to6.5.1.Ensure that an active EHS Program exists within the Institute.6.5.2.Support and promote this EHS Program.



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6.5.3.Review and respond to the annual EHS Audit.6.5.4.Seek adequate funding for environmental, health, and safety issues.6.5.5.Authorize changes in the EHS Program.6.5.6.Appoint an EHS Manager and members of the EHS Committee.6.5.7.Delegate environmental, health, and safety responsibilities as applicable.

7.Audit and Inspection of the EHS Program7.1.Quarterly inspections and an annual audit of the EHS Program will be conducted under

the direction of the EHS Manager.

7.2.Other inspections, announced or unannounced, may be conducted at the discretion of theEHS Manager or upon request of the EHS Committee, the Director, or Section Chief.

7.2.1.The goal of these activities is to assist in maintaining a safe working environment,to further compliance with environmental and safety regulations, and to implementthe EHS Program.

7.3.Results of environmental, health, and safety inspections and the annual Program auditwill be communicated to the EHS Committee and the Director.

8.Reporting EHS Concerns8.1.Staff requests for review of environmental, health, and safety issues should be discussed

with a supervisor and/or submitted in writing to the EHS Manager.

8.1.1.The supervisor will evaluate the request for review and implement resolution asapplicable and/or refer the review to the EHS Manager.

8.1.2.The EHS Manager will investigate the request for review and refer it to anappropriate supervisor, the EHS Committee, and/or the Executive Committee forevaluation.

8.1.3.Corrective action as applicable will be coordinated through the EHS Manager.8.2.As needed, the EHS Manager may convene the EHS Committee or Executive

Committee to review staff requests or any aspect of the EHS Program.

9.EHS Training and Retraining9.1.All employees will receive initial training in applicable aspects of the EHS Program

prior to performing work which may reasonably be expected to involve potentialoccupational exposure.

9.2.All employees will also receive annual refresher training in selected environmental,health, and safety areas including the Biological Exposure Control Plan.

9.3.Selected staff located throughout the facility will receive training and maintaincertification in first aid and CPR.

9.4.Training records will be maintained under the direction of the Quality Manager asoutlined in the Quality Manual.



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9.5.Supervisors will provide additional procedure and laboratory specific training asnecessary to new employees, newly assigned employees, retraining of employees, and

during implementation or modification of procedures.

9.6.As a means of addressing environmental, health, and safety concerns, supervisors mayrequire that an employee receive training or retraining in selected environmental, health,

and safety areas.

10.Authorization of the EHS Program10.1.Implementation of this EHS Program requires authorization of the Director.10.2.The official EHS Program manual is maintained under the direction of the Quality

Manager and is available to staff in electronic format.

10.3.The Program is reviewed annually by the EHS Manager and Committee.10.4.Changes in the written EHS Program must be authorized by the Director prior to

implementation.

10.5.Outdated versions of the manual are archived under the direction of the Quality Manager.11.Recordkeeping

11.1.Training records will be maintained under the direction of the Quality Manager asoutlined in the Quality Manual.

11.2.Written materials related to the EHS Committee, safety inspections, and audits reside withthe EHS Manager and will be kept a minimum of five years.

11.3.The Sharps Injury Log and other personnel records reside in Administration.11.4.Availability and retention of information is consistent with the policies and procedures of

IFS and/or policies, procedures, and direction from Dallas County Human Resources,District Attorneys Office, and/or Sheriffs Office.

12.Visitors12.1.Visitors, interns, or other non-Institute personnel are required to follow this EHS Plan as a

condition of facility access.12.2.It is the responsibility of the hosting IFS employee to ensure that visitors receive necessary

training prior to conducting activities that may reasonably result in occupational exposure,

and sign the Visitors Waiver located in the Security Manual as appropriate.12.3.It is the responsibility of the Institute host to ensure that non-Institute personnel follow

proper procedure.

12.4.The IFS host is responsible for ensuring that all visitor exposures and injuries areimmediately reported to a supervisor and/or Administration.



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Dallas County Institute of Forensic Sciences 1 Facility Emergency Response Plan



FACILITY EMERGENCY RESPONSE PLAN

1.Purpose1.1.The purpose of this plan is to outline the expected response of building occupants to

various emergency situations which could occur at the Institute of Forensic Sciences

including those emergencies which require evacuation or relocation of occupants.

1.2.This procedure outlines expected response to a wide range of potential natural and man-made emergencies including but not limited to fire, severe storm, flammable and toxicmaterial release, bomb threat, civil disturbance, and physical plant emergency.

2.Dispatching Emergency Responders2.1.Inactivate fire or policy emergency response, 911 must be called.

2.1.1.The Fire Department is not automatically notified when the fire/emergency alarmactivates.

2.2.Where possible, 911 should be called by the Lead Emergency Warden or aknowledgeable supervisor.

2.3.However, all employees are authorized to contact 911 should the need arise.2.3.1.The Lead Emergency Warden, Administration, and the Dallas County Fire Marshal

should be notified immediately when this action is taken.

3.Responsibilities3.1.All Employees have the responsibility to

3.1.1.Know location of fire/emergency alarms and emergency exits.3.1.2.Know your Emergency Wardens and be prepared to follow their direction.3.1.3.Be prepared to warn coworkers and activate fire/emergency alarm as necessary -

for example in a fire situation or when staff needs to evacuate the building such as

in a large chemical spill.3.1.4.Immediately evacuate the building at the sound of the fire/emergency alarm or

relocate, evacuate, or shelter in place (lock down) as directed by emergency

wardens or supervisory staff.3.1.5.Ensure all in the immediate area know an emergency exists and are preparing to

evacuate, relocate, or shelter in place (lock down).

3.1.6.Close (and lock if time allows) room/lab doors upon exiting forevacuation/relocation.

3.1.7.Advise visitors of appropriate action to follow in an emergency and be prepared toaccount for visitors at the relocation or evacuation checkpoint or via office

telephones or the emergency warden radio system.3.1.8.Check in with your emergency warden at the relocation or evacuation checkpoint

or using an office telephone or the emergency warden radio system.

3.1.9.Remain in the evacuation, relocation, or lock down area until advised by theDirector, Fire Marshal, Lead Emergency Warden, or their designee.



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3.1.10.Participate in drills and training.3.1.11.Do not use elevators during an evacuation/relocation.3.1.12.Immediately (and prior to an incident), advise supervisors if you are physically

unable to evacuate/relocate using the stairwell or unable to hear the fire alarm.3.2.Emergency Wardens have the responsibility to

3.2.1.Attend training as provided by Dallas County and be prepared, able, and willing toimplement procedures outlined in this manual and the Dallas County Emergency

Warden Handbook.

3.2.2.Know the location of the IFS emergency stretcher and know how to assemble anduse it.

3.2.3.Upon hearing the fire/emergency alarm or receiving instructions from the LeadEmergency Warden or Fire Marshal, instruct individuals on your assigned floor to

begin evacuation/relocation procedures:

3.2.3.1.Know areas in which the fire/emergency alarm may not be heard well (forexample walk-in refrigerators and freezers) and search these areas for people.

3.2.3.2.Know people who may need physical or auditory assistance and ensure thatthey can safely evacuate/relocate.3.2.3.3.With the assistance of other wardens and supervisory staff, ensure all peoplehave left your assigned floor during an evacuation.

3.2.3.4.Take a phone list or roster to the evacuation/emergency checkpoint andaccount for staff and visitors on your floor.

3.2.3.5.Maintain a phone list or roster in the primary work area for us during a lockdown to account for staff using office phones or the emergency warden radio

system.3.2.3.6.Provide your roster reconciliation report to the Lead Emergency Warden or

designee.3.2.3.7.Assist the Lead Emergency Warden and the Dallas County Fire Marshal as

directed.

3.2.4.Provide area-specific emergency orientation to new employees and retraining tostaff as applicable.

3.2.5.Assess effectiveness of drills and relocations and make recommendations toimprove emergency response.

3.3.Lead Emergency Warden has the responsibility to3.3.1.Work with supervisors, Director, IFS EHS Manager, and Fire Marshal to

implement emergency response procedures.3.3.2.Identify and train Emergency Wardens.3.3.3.Coordinate activities of Emergency Wardens and communicate instructions to

Emergency Wardens in an emergency situation.

3.3.4.Be a liaison between the Fire Marshal and IFS staff during an emergency situation.3.3.5.Oversee accountability of staff and visitors during an evacuation, relocation, or

shelter in place (lock down).

3.3.6.Advise Administration and the Fire Marshal immediately if the emergencyresponse plan is activated.

3.3.7.Plan emergency drills and assess response to drills and activation of the plan.3.3.8.Update and post emergency evacuation and fire warden information.



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3.3.9.Review condition of emergency evacuation routes, availability of emergencyequipment such as fire blankets, and the availability of IFS stretcher.

3.4.Records Department Staff and Autopsy Staff Assigned to Back Dock have theresponsibility to

3.4.1.Instruct individuals in the lobby and morgue bay to immediately exit the buildingduring an emergency situation (Autopsy staff).3.4.2.Bring applicable Visitor Logs to the evacuation/relocation checkpoint and give tothe applicable Emergency Warden (Autopsy and Records staff).

3.5.Supervisors have the responsibility to3.5.1.Support the Emergency Warden program.3.5.2.Work with the Emergency Wardens to ensure effective and efficient emergency

response including accountability of personnel.

3.5.3.Ensure staff is trained and actively participates in this program.3.6.Director has the responsibility to

3.6.1.Support the Emergency Response Program and ensure effective facility emergencyresponse.

4.Emergency Procedures Major Event4.1.Evacuation

4.1.1.Upon hearing the fire alarm, employees will implement the Facility EmergencyResponse Plan and evacuate the building as noted below unless directed otherwise

by supervisors or Emergency Wardens.

4.1.2.First through Fourth Floors4.1.2.1.Take the closest stairwell to the first floor and exit the building via the two

back emergency doors and assemble in the UT-Southwestern parking lot.4.1.2.2.Check in with your Emergency Warden.4.1.2.3.Stay calm.4.1.2.4.Remain at the assembly point until advised otherwise by the Director, Fire

Marshal, Lead Emergency Warden, or their designee.

4.1.3.Basement (Morgue)4.1.3.1.Immediately exit using the dock bay exit and assemble in the IFS back

parking lot.

4.1.3.2.Check in with your Emergency Warden.4.1.3.3.Stay calm.4.1.3.4.Remain at the assembly point until advised otherwise by the Director, Fire

Marshal, Lead Emergency Warden, or their designee.

4.2.Severe Weather Relocation4.2.1.Emergency Wardens will advise staff to relocate due to imminent severe weather.4.2.2.Where possible staff will relocate based upon their assigned work area.

4.2.2.1.Morgue Staff4.2.2.1.1.Emergency Wardens will instruct employees and visitors to remain in

the basement.

4.2.2.2.First Floor4.2.2.2.1.Emergency Wardens will instruct employees and visitors to move into

the first floor hall and close office doors.



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4.2.2.3.Second, Third, and Fourth Floors4.2.2.3.1.Emergency Wardens will instruct employees and visitors to move to the

assigned stairwell.

4.2.3.Staff will check in with their Emergency Warden.4.2.4.Staff will remain at your assembly point until advised by Emergency Warden or

supervisor.4.3.Facility Lock Down4.3.1.A facility lock down will be initiated in response to a threat of violence within the

facility or to protect staff in place.

4.3.2.The first staff to perceive the potential threat will immediately leave the area ofdanger and go to the nearest room which can be physically locked from the inside.

4.3.3.Staff will immediately call the switchboard operator or Field Agent Office (0 or5900) to initiate a lock down of the entire building.

4.3.4.Records Staff4.3.4.1.Records Staff will likely be the first to perceive a threat.4.3.4.2.Staff will alert other staff in the area and go immediately into telephone room

through back door.4.3.4.3.Staff will immediately call the switchboard operator or Field Agent Office(0 or 5990) to initiate a lock down of building.

4.3.4.4.If necessary and if safe to do so, Records staff will exit the building throughthe Parkland entrance and evacuate to UT-Southwestern outside cafeteria.

4.3.4.4.1.They should physically lock the Parkland entrance as they leave ifpossible.

4.3.5.Switchboard Operator and Lead/Assistant Lead Wardens4.3.5.1.Operator should immediately notify Administration and/or Senior Field

Agent (Lead or Assistant Lead Wardens) to initiate appropriate response.4.3.5.2.Operator may be directed to initiate building lock down by calling

Emergency Wardens.

4.3.6.Lead/Assistant Warden should determine the need for outside response and seekassistance as applicable:

4.3.6.1.Call 911, DSS, Parkland Security, and/or Dallas County Sheriffs Officedispatch.

4.3.6.2.Initiate Field Agent Emergency Cell Phone Backup Plan if appropriate.4.3.7.First through Fourth Floors

4.3.7.1.Staff should immediately proceed to the nearest physically lockable room andstay there until notified.

4.3.7.2.Staff will not use elevators until notified by Emergency Wardens or InstituteAdministration.

4.3.7.3.Floor Wardens will initiate roster check by phone and using the IFSemergency radio system.

4.3.8.Morgue4.3.8.1.Staff will remain in basement until notified.4.3.8.2.Staff will not use elevators until notified by Emergency Wardens or Institute

Administration.



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4.3.9.If a threat begins in loading dock area, IFS staff in the area should immediatelyleave the area, proceed to the far stairwell, and alert all staff along the way to go to

the first floor.

4.3.10.Staff in the Morgue should immediately report to the Field Agent Office for lockdown and initiate building-wide response as noted above.

4.4.Other Response4.4.1.Follow instructions of the Emergency Wardens and supervisors.

4.4.2.In some cases, staff and visitors may be directed to evacuate through the coveredwalkway to UT-Southwestern.

4.4.2.1.In this case, the assembly point is the hallway outside the UT-Southwesterncafeteria.

5.Emergency Procedures Minor Event5.1.Any unsafe or suspected emergency situation must be immediately reported to a

supervisor and Administration for assessment.

5.2.When in doubt, activate the Facility Emergency Response Plan by contacting anEmergency Warden or a supervisor or by activating the fire/emergency alarm.

6.After-hours Emergency Response6.1.After regular business hours (8:00 am 4:30 pm Monday through Friday), all staff and

visitors are expected to evacuate the building at the sound of the fire/emergency alarm.

6.2.The main building entrance will be the evacuation point for the first through fourthfloors.

6.3.Individuals in the basement will exit through the dock exit.6.4.The assembly point for all staff and visitors will be the parking lot in front of the

building.

6.5.The senior field agent on-duty will act as the Lead Emergency Warden, immediately call911 if required, and take the main entry Visitor Log to the assembly point.

6.6.The senior field agent on-duty will contact the Chief Field Agent, Administration, andthe Dallas County Fire Marshal.

7.Staff Accountability During Non-Standard Work Hours7.1.Purpose

7.1.1.This procedure is intended to assist Field Agents during a facility emergency inaccounting for IFS staff in the building outside normal working hours.

7.1.1.1.Crime Lab staff working outside the hours of 6 AM 6 PM Monday throughFriday must log in and out on the Visitors Log.

7.1.1.2.OME staff working outside the hours of 6 AM 6 PM Monday throughFriday and outside their assigned shift must log in and out on the Visitors Log.

7.2.Logging in procedure7.2.1.To log in, the staff member must

7.2.1.1.Sign in using the visitor form at the front office window indicating on theform:



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7.2.1.1.1.The staff members name.7.2.1.1.2.The date and time of arrival.7.2.1.1.3.The section/laboratory where the staff member will be working.7.2.1.1.4.The primary contact phone number to be used in the event of an

emergency.

7.3.Logging out procedure7.3.1. To log out, the staff member must:

7.3.1.1.Sign out using the visitor guest form at the front office window indicating thedate and time of departure on the visitor form.

7.4.Procedures for arriving to work before 6 AM on a scheduled work day.7.4.1.A Crime Lab staff member who arrives to work before 6 AM on a regular work

day and works into the regular work hours must log in as noted above but does not

need to log out.

7.4.2.This section does not apply to OME staff.7.5.Procedures for working after 6 PM on a scheduled work day.

7.5.1.A Crime Lab staff member who works beyond 6 PM on a scheduled work daymust log in before 6 PM and log out of the building upon leaving as noted above.7.5.2.This section does not apply to OME staff.

8.Physical Plant Emergency8.1.Any physical plant emergency such as major water leak, electrical outage, etc. - will be

immediately reported to Administration who will contact Facilities Management as

directed in the Dallas County Telephone Directory.8.2.After regular business hours, these emergencies should be reported to an on-duty Field

Agent who is responsible for contacting Facilities Management andsupervisors/Administration as appropriate.

9.Location of Emergency Exits and Identification of Emergency Wardens and StaffTrained in First Aid and CPR

9.1.Location of emergency exits and a list of area Emergency Wardens and staff trained infirst aid and CPR are posted near each stairwell.



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Dallas County Institute of Forensic Sciences 1 Safe Operating Procedures

Environmental, Health, and Safety Program Version 2.0


GENERAL SAFE OPERATING PROCEDURES

1.Purpose1.1.The purpose of this section is to review general safe operating procedures.1.2.More specific and detailed policies and procedures may be found in other sections of the

EHS Manual and/or unit procedure manuals.

2.Routes of Exposure2.1.Reagents, samples, specimens, and other evidence submitted to IFS are potential sources

of chemical, biological, and physical hazards.2.1.1.During the collection, processing, and testing of all materials, employees should

remain aware of potential sources of hazards and minimize exposure.

2.2.Absorption2.2.1.Open cuts or scratches on the skin, particularly the hands, provide a point of entry

for chemicals and biologicals.

2.2.2.Some infecting agents and chemicals can penetrate intact skin, the conjunctiva ofthe eye, and other mucous membranes.

2.2.3.Protection2.2.3.1.Protection is provided by wearing proper gloves, safety glasses, face shield,

lab coat, and other personal protective equipment (PPE) which shield the bodyfrom potential exposure.

2.3.Aerosols2.3.1.Biologicals and chemicals may become airborne through a variety of laboratory

procedures or accidents including spills, broken containers, centrifuging, vortexing,

pipet transfer, sample homogenization, splashing and flaking of materials, removingcaps or stoppers, firing weapons, mechanical handling of clothing and other

specimens, and autopsy procedures such as sawing.

2.3.2.Aerosols may be inhaled into the lungs and absorbed into the body.2.3.3.Protection

2.3.3.1.Protection against inhalational hazards is provided by proper fitting masksand use of ventilation such as hoods.

2.3.3.2.Centrifuges should come to a complete stop prior to opening to avoidbreathing any materials aerosolized during centrifugation.

2.3.3.3.Vacutainer tubes should be opened using a gauze covering or similar deviceto trap any materials aerosolized as the vacuum is broken.

2.4.Direct Inoculation2.4.1.Broken glassware, needles, syringes, forceps, staples on packaging materials, and

other sharp objects provide a direct means of injection of infecting agents orchemicals into the body.

2.4.2.Other sources of direct inoculation include sharps used in specimen collection,ticks, fleas, body lice and other ectoparasites.

2.4.3.Protection



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2.4.3.1.Use of safer sharps, personal protective equipment, and safe work practicescan provide protection.

2.5.Ingestion2.5.1.Smoking, eating, or drinking after handling evidence, reagents, or specimens and

prior to washing hands may result in oral ingestion of infective agents or chemicals.

2.5.2.Mouth pipeting, placing objects such as pens and pencils in ones mouth, orhand/glove contact with skin or mucous membranes may also result in

contamination.

2.5.3.Protection2.5.3.1.Eating and drinking is only allowed in designated clean areas.2.5.3.2.Smoking is not allowed within IFS or in County vehicles and is only

permitted in specifically designated areas outside the building.

2.5.3.3.Staff should wash hands frequently with soap and water. When this is notavailable, staff should use waterless degermer (hand sanitizer) followed byhand washing at the first available opportunity.

2.5.3.4.Do not place foreign objects in your mouth.2.5.3.5.

Remove gloves before contacting unprotected skin, eyes, or mucousmembranes.

2.6.Radiation2.6.1.Energy emitted from various instruments poses a special danger to skin and eyes.2.6.2.Protection

2.6.2.1.Protective glasses should be worn to guard against ultraviolet, infrared, orlaser radiation.

2.6.2.2.Shielding and distance protocols must be followed to minimize exposure toradioactive materials or X-ray generating instrumentation.

2.6.2.3.Radiation dosimetry badges must be worn when operating x-ray equipment.2.6.2.3.1.Radiation dosimetery badges must be handled as required by the

Radiation Safety Program.

3.General Safety Procedures3.1.Routinely wash hands with disinfectant soap and water.

3.1.1.When hand washing is not possible, disinfect hands using waterless degermer(hand sanitizer) until hand washing facilities become available.

3.2.Use personal protective equipment such as gloves, safety goggles, lab coats, aprons,tyvek suits, and masks to minimize exposure.

3.3.Avoid touching unprotected body areas or clean items with gloved or unwashed hands.3.4.Use hoods or increased ventilation to decrease the potential for exposure in applicable

processes.3.4.1.Ensure that filters (such as HEPA or charcoal filters) on hoods and vents are

changed per manufacturers instructions.

3.5.Develop a written general housekeeping procedure for each area and documentcompliance.

3.6.Keep your work area neat and clean.3.7.Do not smoke within IFS or County vehicles or outside specifically permitted areas.3.8.Do not pipet by mouth.



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3.9.Eat, drink, and store food or beverages only in designated areas; do not store food inlaboratory or morgue refrigerators.

3.10.Do not use lab or morgue glassware or materials for the preparation or consumption offood or beverages.

3.11.Do not wash items used in the preparation or consumption of food or beverages withlab or morgue glassware.3.12.Avoid creating and inhaling chemical or biological dusts or aerosols.

3.13.Wear dosimeters as issued.3.14.Operate all equipment that generates X-rays from a shielded location. Ensure that co-

workers are also in a shielded location and that the doors to the X-ray room are closed.

3.15.Take advantage of occupational exposure testing (such as for lead and TB) andvaccinations (such as for hepatitis B) as available and appropriate.

3.16.Do not wear open-toe shoes in the lab or morgue areas.3.17.Do not store corrosive chemicals above eye level.3.18.Use a dolly to transport capped gas cylinders and make sure cylinders are securely

fastened to the wall or bench top. Use proper and compatible fittings, gauges, and

regulators.3.19.Dispose of broken or damaged glassware in designated containers.3.20.Use proper lifting techniques; get assistance if an item is too bulky or too heavy to be

moved by one person.3.21.Adjust your workstation to prevent ergonomic strain. Take a short break from typing

each hour and exercise your arm. Alternate typing with other non-typing job duties.

3.22.Remove lab coats and other personal protective equipment prior to leaving a chemicalor biological work area. Wash hands after removing gloves.

3.23.Clean up spills of biologicals and chemicals as soon as possible. Seek assistance fromyour supervisor or the EHS Manager or Deputy with large spills or if spill exceeds yourcapacity and training to respond.

3.24.Suspected explosive materials and other dangerous materials not routinely tested at IFSwill not be accepted as evidence. Submitters will be directed to appropriate agencies asavailable.

3.25.IFS staff are not authorized to carry firearms (personal or otherwise) while on duty.This restriction does not refer to appropriate handling or processing of evidence byauthorized individuals.

3.26.All items used as personal protective equipment including lab coats must be launderedor properly disposed at IFS. These items may not be laundered or disposed at home.

3.27.Dispose of chemicals and biologicals properly; see applicable parts of the EHS Manualor contact the EHS Manager.

3.28.For both safety and quality concerns, all broken or malfunctioning equipment must belabeled as such.

3.29.Do not use cracked or broken glassware.3.30.Practice Universal Precautions at all times while working with biologicals.3.31.Read the MSDS and container label prior to working with a chemical.3.32.Do not use chemicals from unlabeled containers.3.33.Keep exits and stairwells clear of obstructions; do not store items in stairwells.3.34.Do not take chances; ask for help.3.35.Seek supervisory assistance if you are unsure.



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3.36.Use common sense and professional training.3.37.Report unsafe conditions to your supervisor, the EHS Manager, and/or Committee.

4.Area Specific Issues4.1.

Handling and Use of Firearms and Ammunition4.1.1.Loaded firearms will not routinely be accepted as evidence.

4.1.1.1.Loaded firearms which are physically unable to be unloaded may be acceptedprovided that a supervisor or Firearms examiner immediately takes possession

of the weapon.

4.1.2.All firearms and ammunition will be handled as if it is functionally operational.4.1.3.All firearms will be treated as if they are loaded until a safety inspection ensures

that the weapon is unloaded.

4.1.4.No firearm should be loaded except in designated test-firing areas. The bore of theweapon will be checked for obstruction prior to loading.

4.1.5.Firearms will not be pointed at another person.4.1.6.

Supervisors are responsible for instructing the firearms examiner in the properhandling of firearms.

4.1.7.Eye and ear protection will be worn when test firing.4.1.8.If doubt exists as to the safety of direct firing, a remote device will be employed.4.1.9.Test firing observers will view from a window or other shielded location.4.1.10.As available, filters and fans will be used to minimize exposure to airborne

materials.

4.1.11.All shooting will be performed by Firearms staff, observed by Firearms staff, orspecifically approved by the Section Chief or Director.

4.1.12.Proper maintenance and care of bullet recovery systems will be performed on aroutine basis.

4.1.13.Occupational testing for lead and hearing will be offered annually tooccupationally exposed individuals.

4.1.14.Ammunition and similar materials will be handled and stored followingapplicable regulations.

4.1.15.Non-routine use of a firearm (including classroom instruction) must be approvedby the Section Chief or Director.

4.2.Handling and Use of Alternate Light Sources4.2.1.Goggles, other appropriate filters, or other safety measures will be used to

minimize radiation exposure form alternate light sources which may cause eye or

skin damage. The operator and any observers must be provided with adequate

protection.

4.2.2.Alternate light sources will be operated by individuals trained in their use.4.2.3.Operators and observers may never look directly into an alternate light source

aperture when the unit is emitting light; protection must be provided against both

direct and reflected light.4.2.4.Procedures should be developed to minimize stray reflections; for example, optical

elements or shiny objects should not be moved into or out of the light path of the

alternate light source unless filter barriers or other approved safety measures areused.



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4.2.5.Instrument safety mechanisms such as interlock devices may not be tampered with.4.2.6.The alternate light source should be turned off or power decreased when not in use.

5.Safety Equipment5.1.

Be familiar with the location and use of safety equipment in your work area. Contactyour supervisor or the EHS Manager for assistance or training.

5.2.Fire Extinguishers are located throughout the building.5.3.Eyewash fountains and/or bottles are located in all laboratories and in the morgue.5.4.Hand washing facilities and/or waterless degermer are located in restrooms, laboratories,

the morgue, and throughout the building.5.5.Hoods and other ventilation devices are available to prevent exposure to airborne

substances.

5.6.Labels and safety notices/warnings are posted as applicable throughout the building.5.7.Spill kits are located in labs, the morgue, and back dock.5.8.Chemical storage areas, including flammables and corrosives cabinets, are located

throughout the lab areas.5.9.The gas cylinder dolly is located in the vicinity of the gas storage area.5.10.Designated waste containers are located throughout the lab and morgue areas.5.11.Safety showers are located on the second floor (Toxicology Lab and hallway), third

floor (hallway near Firearms), fourth floor (laundry), and morgue (autopsy area and

morgue clerk area).

5.12.First aid kits are located in all labs, morgue, and the Field Agent area.5.12.1.The first aid kit in the Field Agent area contains a selection of over the counter

pharmaceuticals available for employee use.

5.13.Fire blankets are available in the morgue and all lab areas.5.14.The IFS stretcher chair is located near the safety shower on the 3 rd floor.

6.Inspection of Safety Equipment6.1.Safety equipment is checked as part of the quarterly EHS audit.6.2.Hoods are checked quarterly to assure function and to mark flow of 100 ft/min.

6.2.1.Hoods should be operated with the sash near the 100 ft/min mark.7.Infrastructure Safety Features

7.1.Maintenance of building infrastructure is the responsibility of Facilities Management.7.1.1.Electrical outlets used in close proximity to running water in the Morgue must be

equipped with a ground fault interrupt which should be tested annually under thedirection of Facilities Management.

7.1.2.Autopsy dissecting sinks must be equipped with back flow protection and testedunder the direction of Facilities Management as required by regulation.



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Dallas County/Southwestern Institute of Forensic Sciences

BIOLOGICAL EXPOSURE CONTROL PLAN

Bloodborne Pathogens Exposure Control Plan

1.Goals and Regulatory Compliance

1.1.The Dallas County Institute of Forensic Sciences is committed to providing a safe andhealthful work environment for all staff and others who work or visit in this facility.

1.2.To support this commitment, a biological exposure control plan has been developed tominimize occupational exposure to bloodborne pathogens in accordance with the TexasHealth and Safety Code, Chapter 81, Subchapter H which is consistent with the OSHA

Bloodborne Pathogens Standard.

1.2.1.Additional information may be found in the Texas Administrative Code, Title 25,Part 1, Chapter 96.

2.Relationship to Dallas County Policy and Procedure

2.1.Dallas County policies and procedures will be followed in responding to a suspectedbiological exposure.

2.1.1.Specific instructions detailing how to receive a post biological exposureevaluation may be found in the Blood/Body Fluid Exposure Protocol notebook

located in the Field Agent area; evaluations are available 24 hours a day.

2.1.2.An employee involved in a suspected biological exposure incident mustimmediately notify his supervisor if available.

2.2.The Biological Exposure Control Plan is administered jointly with the Dallas CountyWorkers Compensation Program and Family and Medical Leave Act Program and does

not replace or supercede any portion of Dallas County policy, specifically the Workers

Compensation or Dallas County occupational control process.

3.Selected Definitions: Refer to regulations listed in Section 1 for additional definitions.3.1.Bloodborne pathogens Pathogenic microorganisms that are present in human blood

and that can cause diseases in humans, and include hepatitis B virus (HBV), hepatitis C

virus (HCV), and human immunodeficiency virus (HIV).3.2.Contaminated The presence or reasonably anticipated presence of blood or other

potentially infectious material on an item or surface.

3.3.Employee An individual who works for a governmental unit or on premises owned oroperated by a governmental unit whether or not he or she is directly compensated by thegovernmental unit.

3.4.Exposure incident A specific eye, mouth, or other mucous membrane, non-intact skin,or parenteral contact with blood or other potentially infectious materials that results fromthe performance of an employees duties.

3.5.Occupational exposure A reasonably anticipated skin, eye, mucous membrane, orparenteral contact with blood or other potentially infectious materials that may resultfrom the performance of an employees duties.

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3.6.Other potentially infectious materials Semen, vaginal secretions, cerebrospinal fluid(CSF), synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid,

saliva in dental procedures; any body fluid that is visibly contaminated with blood; all

body fluids in situations where it is difficult or impossible to differentiate between bodyfluids; any unfixed tissue or organ (other than intact skin) from a human, living or dead.

3.7.Parenteral Piercing mucous membranes or the skin barrier through such events asneedlesticks, human bites, cuts, and abrasions.

3.8.Personal protective equipment (PPE) Specialized clothing or equipment worn by anemployee for protection against a hazard. General work clothes (e.g., uniforms, pants,

shirts, or blouses) not intended to function as protection against a hazard are not

considered to be personal protective equipment.3.9.Sharp An object used or encountered in a health care setting that can be reasonably

anticipated to penetrate the skin or any other part of the body and to result in an exposure

incident and includes: needle devices, scalpels, lancets, broken glass, broken capillarytube, exposed dental wire, dental knife, drill, or bur.

3.10.Sharps injury Any injury caused by a sharp, including a cut, abrasion, orneedlestick.3.11.Universal precautions All human blood and certain human body fluids are treated asif known to be infectious for HIV, hepatitis, and other bloodborne pathogens. Therefore

appropriate preventive measures must be used by employees when working withcontaminated materials. Preventive measures encompass using both engineering and

work practice controls and personal protective equipment.

4.Employee Exposure Determination4.1.The Texas Department of Health (TDH) Bloodborne Pathogen Exposure Control Plan

requires employers to perform an exposure determination to identify employees who

have occupational exposure to blood or other potentially infectious materials.

4.1.1.The exposure determination is made without regard to the use of personalprotective equipment or frequency of exposure.

4.2.Because of the widespread presence of biologicals at the Institute, all employees willreceive biohazard training.

4.3.In the situation in which an employee moves from performing job duties with nooccupational exposure to duties with occupational exposure, it is the responsibility of the

supervisor to ensure that the employee receives additional training as necessary andpersonal protective equipment as appropriate.

4.4.The following is a list of all job classifications at the Dallas County Institute of ForensicSciences in which allemployees within the job title have occupational exposure:

Job Title Department/SectionDrug Chemist II Crime Lab/Forensic Chemistry

Drug Chemist III Crime Lab/Forensic Chemistry

Drug Supervisor Crime Lab/Forensic Chemistry

Forensic Chemistry Chief Crime Lab/Forensic Chemistry

Forensic Chemistry Deputy Chief Crime Lab/Forensic Chemistry

Laboratory Aide Crime Lab/Forensic Chemistry

Toxicology Chemist II Crime Lab/Forensic Chemistry





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Toxicology Chemist III Crime Lab/Forensic Chemistry

Toxicology Supervisor Crime Lab/Forensic Chemistry

Firearms Examiner Crime Lab/Physical Evidence

Firearms Supervisor Crime Lab/Physical Evidence

Forensic Biologist II Crime Lab/Physical Evidence

Forensic Biologist III Crime Lab/Physical Evidence

Forensic Biology Supervisor Crime Lab/Physical EvidencePhysical Evidence Chief Crime Lab/Physical Evidence

Physical Evidence Deputy Chief Crime Lab/Physical Evidence

Trace Evidence Examiner Crime Lab/Physical Evidence

Trace Evidence Supervisor Crime Lab/Physical Evidence

Director Medical Examiner/Administration

Utility Clerk Medical Examiner/Administration

Autopsy Room Assistant Supervisor Medical Examiner/Autopsy Services

Autopsy Room Supervisor Medical Examiner/Autopsy Services

Autopsy Technician Medical Examiner/Autopsy Services

Medical Examiner Medical Examiner/Autopsy Services

Medical Examiner Chief Deputy Medical Examiner/Autopsy Services

Pathologist Medical Examiner/Autopsy Services

Field Agent Medical Examiner/Medicolegal Death InvestigationField Agent Assistant Chief Medical Examiner/Medicolegal Death Investigation

Field Agent Chief Medical Examiner/Medicolegal Death Investigation

4.5.The following is a list of all job classifications at the Dallas County Institute of ForensicSciences in which someemployees within the job title have occupational exposure.

Job Title Department/Sections Tasks or Specific Position

with Potential Biological

ExposureEvidence Registrars Crime Lab/Physical Evidence and

Forensic Chemistry

Toxicology and PES Evidence

Registrars

Secretary Crime Lab/Physical Evidence Back-up Evidence Registration byPES Secretary

Clerk II Crime Lab/Forensic Chemistry Back-up Laboratory Aide and

Evidence Registration functions by

Toxicology Clerk II

5.Methods of Implementation and Exposure Control5.1.Biological exposures at the Institute are controlled through a combination of methods

including the implementation and use of universal precautions, engineering and work

practice controls, personal protective equipment (PPE), housekeeping measures,management of biological spills, disposal of regulated biological waste, laundry

procedures, and hepatitis B vaccine.

5.2.Universal Precautions5.2.1.Universal precautions are observed throughout the Institute to prevent exposure to

blood or other potentially infectious materials. All blood or other potentially

infectious materials are considered infectious regardless of the perceived status ofthe source individual.

5.3.Engineering and Work Practice ControlsInstitute of Forensic Sciences 3 Biological Exposure Control Plan




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5.3.1.Engineering and work practice controls are used to prevent or minimize exposureto bloodborne pathogens.

5.3.2.Employees and supervisors must examine and maintain engineering and workpractice controls within a biological work area.

5.3.3.Hand washing5.3.3.1.

Hand washing must be performed routinely throughout the day, for example,after handling biological materials, after a suspected biological exposure, after

removing gloves, after removing personal protective equipment, when leaving

a biological work area.

5.3.3.2.Hands should be washed thoroughly on both sides, between fingers, andabove wrist with antimicrobial soap and running water. Designated handwashing sinks should be used where they are available.

5.3.3.3.In certain situations, hand washing facilities are not readily available, forexample, field work, removal of shoe covers in morgue, etc. In thesecircumstances, employees must ensure availability of and use antiseptic

cleanser with clean paper towels, antiseptic towelettes, and/or waterless

disinfectant as available.5.3.3.3.1.Hands must be washed with soap and running water as soon as feasible.5.3.4.Suspected Biological Exposure

5.3.4.1.If an individual suspects biological exposure to skin or mucous membranes,those areas must be washed with soap and water as soon as possible following

contact; after an eye exposure, the eye should be flushed with water as soon as

possible.

5.3.4.2.Information regarding post-exposure medical assessment may be found in theBlood/Body Fluid Exposure Protocol notebook located in the Field Agent

Office.5.3.5.Needles and Sharps

5.3.5.1.Where applicable and approved by the EHS Committee, safer designedsharps must be used.

5.3.5.2.Contaminated needles and other contaminated sharps should not be bent,recapped, removed, sheared, or purposely broken.

5.3.5.2.1.In some cases for example when syringes are submitted as evidencefor analysis an exception to this may be made if no alternative is

feasible and the action is required to analyze the item or render it safe for

future handling as evidence. If such action is required, recapping orremoval of the needle must be done by the use of a device or a one-

handed technique.

5.3.5.3.Sharps evidence must be contained in a hard-sided container for storage andtransport.

5.3.6.Sharps Containment and Disposal5.3.6.1.Contaminated sharps including broken glass must be discarded immediately

or as soon as feasible in containers that can be closed, are leak-proof on sidesand bottom, and are labeled or color-coded as a biohazard.

5.3.6.2.Use forceps, a scoop, or some other mechanical means to remove the brokenglass or other sharps to avoid a sharps injury.

5.3.6.3.Sharps disposal containers must be located in an easily accessible location asInstitute of Forensic Sciences 4 Biological Exposure Control Plan




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close as feasible to the immediate area where sharps are being used or can bereasonably anticipated to be found.

5.3.6.4.The containers must be maintained upright throughout use, may not beoverfilled, must be closed and replaced routinely, and must be handled as abiohazard waste when discarded.

5.3.7.Work Area Restrictions5.3.7.1.In work areas designated by supervisors as having reasonable likelihood of

exposure to blood or other potentially infectious materials, employees are not

to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses.

5.3.7.2.Food and beverages may not be kept in refrigerators, freezers, shelves,cabinets, or on counter/bench tops where blood or other potentially infectiousmaterials are present.

5.3.7.3.Mouth pipetting of blood or other potentially infectious materials isprohibited.

5.3.7.4.All procedures must be conducted using good laboratory/medical techniqueand in a manner which minimizes splashing, spraying, spattering, and

generation of droplets of blood or other potentially infectious materials.5.3.8.Biohazard Labeling and Color Coding5.3.8.1.The universal biohazard symbol and/or color (red or orange) will be used to

warn of the presence of potential biohazard substances, situations, andlocations within the Institute.

5.3.8.2.Biohazard labeling and/or color coding are used to identify regulatedbiological waste, refrigerators and freezers containing blood and other

potentially infectious materials, and other containers used to store, transport, orship blood or other potentially infectious waste.

5.3.9.Designated Biological Handling Areas5.3.9.1.Areas are marked to advise of the presence of potentially infectious

biological materials.

5.3.9.1.1.Specific areas within a biohazard area may be labeled as a clean area inwhich no biologicals are allowed.

5.3.9.1.2.Alternatively biohazard areas may be designated within otherwise non-biological work areas.

5.3.9.1.2.1.It is not appropriate to designate a clean food consumption areain an otherwise biohazard area.

5.3.9.2.Suggested language for biohazard warning signs in biological work areas isas follows: CAUTION BIOHAZARD: Eating, drinking, applying cosmetics

or lip balm, smoking or handling contact lenses are prohibited in this area.

5.3.10.Specimen Handling and Labeling5.3.10.1.All potentially contaminated evidence and biological specimen collected or

stored at the Institute must be handled as a potential biohazard until the item is

decontaminated or rendered non-infectious (for example by fixation, washing

in bleach solution, solvent extraction, etc.).5.3.10.2.Specimens of blood or other potentially infectious materials must be placed

in a container which prevents leakage during the collection, handling,

processing, storage, transport, or shipping of the specimens.5.3.10.3.Although the Institute uses universal precautions, the outer biological





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specimen container must be marked with a biohazard label or the specimenmust be handled or stored only in a designated biohazard area.

5.3.10.4.Contaminated materials/evidence must be marked with a biohazardlabel prior to releasing to an outside entity or leaving the Institute.

5.3.10.5.If the outside of the primary container becomes contaminated, the primarycontainer must be cleaned as possible and stored in a designated biologicalstorage area or placed into a secondary container which prevents leakageduring the handling, processing, storage, transport, or shipping of the specimen

or other materials.

5.3.10.5.1.The secondary container must be labeled as a biohazard.5.3.10.6.Any specimen which could puncture a primary container must be placed

into a puncture proof secondary container for transport.

5.3.11.Equipment5.3.11.1.Equipment which cannot be easily washed and decontaminated should be

protected from potential biological exposure during use.

5.3.11.1.1.This may be accomplished by covering the operational parts of theequipment with a plastic bag, plastic wrap, or aluminum foil or bydesignating as a clean item.

5.3.11.1.1.1.The disposable covering must be changed as soon as feasibleupon contamination or on a routine basis such as the end of the shift.

5.3.11.2.It is recommended that keyboards used in biological areas should becovered with a plastic keyboard cover which can be cleaned on a regular basis.

5.3.11.3.Contaminated equipment must be marked with a biohazard label ordecontaminated prior to service on or off site.

5.3.12.Case Files5.3.12.1.Case files are designated as clean items.

5.3.12.1.1.Case files must be maintained in clean areas.5.3.12.1.2.Should case contents become contaminated with biologicals,

contaminated paperwork must be photocopied using the copier in themorgue designated for this purpose.

5.3.12.1.2.1.The copy will be marked as a true and exact copy withexplanation, initialed, and the original properly disposed.

5.3.13.Identification Badges5.3.13.1.Employees must position or temporarily remove identification badges so

that they do not become contaminated with biologicals.5.3.13.2.In the event that possible contamination occurs, badges must be cleaned

with disinfectant.

5.3.14.Building Ventilation5.3.14.1.As a general rule, employees may not open windows since this interferes

with proper building pressurization.

5.3.14.2.Facilities is responsible for maintaining air flow systems and changingfilters.

5.3.15.Designated Clean Items5.3.15.1.Certain items such as case files, phones, elevator buttons, and cameras are

designated as clean items.5.3.15.1.1.They must be handled in designated clean areas and may not be





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touched with contaminated gloves or hands.

5.4.Personal Protective Equipment (PPE)5.4.1.Use of PPE is required when engineering and work practice controls do not

eliminate potential occupational exposure to biohazards.5.4.2.PPE is chosen based on the anticipated exposure to blood or potentially infectious

materials.5.4.3.PPE is considered appropriate only if it does not permit blood or other potentiallyinfectious materials to pass through or reach the employees clothing, skin, eyes,

mouth, or other mucous membranes under normal conditions of use and for the

duration of the time which the protective equipment is used.

5.4.4.Examples of PPE include gloves, eyewear with solid side shields, gowns, lab coats,aprons, shoe covers, face shields, and masks.

5.4.5.All PPE must be fluid resistant.5.4.6.PPE is provided at no cost to the employee.5.4.7.PPE is cleaned, laundered, and/or disposed as applicable by the Institute at no cost

to the employee.

5.4.8.Employees should contact their supervisor to request additional or different PPE.5.4.9.All PPE which is penetrated by blood must be removed immediately or as soon as

feasible and placed in an appropriate container.

5.4.10.All PPE must be removed before leaving the biological work area.5.4.11.Routine Use of Personal Protective Equipment

5.4.11.1.Routine use of PPE is outlined for each functional area and is available tostaff in the EHS Resource Document file.

5.4.11.1.1.Staff should contact a supervisor for direction in selection and use ofPPE.

5.4.11.2.Employees will select appropriate personal protective equipment to avoidreasonably anticipated contact of the skin, eye, mouth, and mucous membranes

with biological materials.

5.4.11.3.Variance from procedures established in this Plan must be approved by asupervisor or the EHS Manager prior to implementation.

5.4.12.Gloves5.4.12.1.Gloves are required when handling any material which may reasonably be

expected to have potentially infectious biological contamination.

5.4.12.2.Latex-sensitive employees should advise their supervisors who will arrangefor suitable alternative personal protective equipment.

5.4.12.2.1.If non-latex gloves are worn, it is recommended that they be coveredwith a second latex glove to provide additional protection.

5.4.12.3.Disposable gloves may not be re-used and must be replaced as soon aspractical when they become contaminated or as soon as feasible when they aretorn, punctured, or otherwise unable to provide an effective barrier.

5.4.12.4.Reusable utility gloves may be decontaminated for re-use provided that theintegrity of the glove is not compromised.

5.4.12.4.1.When utility gloves are used as a barrier to biological exposure, it isrecommended that disposable gloves be worn underneath the utility

glove.5.4.12.4.2.Utility gloves must be discarded if they are cracked, peeling, torn,





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punctured, exhibit other signs of deterioration, or are unable to provide aneffective barrier.

5.4.12.5.Vinyl and latex gloves are not puncture proof.5.4.12.5.1.Cut-resistant gloves are available in the morgue and should be

considered for use when manipulating broken bones, bodies with broken

glass, etc.5.4.13.Lab Coat5.4.13.1.A fluid resistant lab coat or similar garment is required when it may be

reasonably expected that potentially infectious material may flake, drip, splash,

spray, drop, or otherwise contaminate work clothes.

5.4.13.2.Medical Examiner lab coats are not worn as PPE.5.4.13.3.Crime Lab lab coats are used as PPE.

5.4.14.Shoe Covers5.4.14.1.Fluid resistant foot covering is required when it may be reasonably expected

that employees will walk in areas containing potentially infectious materials.

5.4.14.2.Shoe covers are required in the Morgue.5.4.14.3.

Shoe covers or boots are required in the field when biologicals are presenton the walking surface.

5.4.15.Plastic Garments5.4.15.1.Fluid impervious garments such as plastic aprons and sleeves, autopsy

smocks, tyvek suits, and similar garments are required when biological

splashes may be expected, when large quantities of blood are present or

anticipated, or when moving a body.

5.4.15.2.These types of garments are indicated in the hot zone at autopsy, at a scenewith extensive biological contamination, when moving a decomposed body,

etc.5.4.16.Head Covering

5.4.16.1.Surgical caps or other head covering is required when biological splashes orspatter may reasonably be expected to reach the head such as in the hot zone atautopsy.

5.4.17.Face and Eye Protection5.4.17.1.Eye protection includes devices such as goggles, glasses with solid side

shields, or chin length face shields.

5.4.17.2.A face shield or eye protection must be used when biological exposure toeyes may be reasonably expected due to a splash, spray, splatter, flaking, ordroplets of blood or other potentially infectious materials.

5.4.17.3.Face shield or eye protection and mask are required when a biologicalsplash to the face may reasonably be anticipated such as in performing an

autopsy.5.4.18.Mask

5.4.18.1.A mask must be worn when biological exposure to nose, mouth, andbreathing zone may be reasonably expected due to a splash, spray, spatter,flaking, or droplets of blood or other potentially infectious materials.

6.Housekeeping





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6.1.The workplace must be maintained in a clean and sanitary condition.6.1.1.General building cleanliness is the responsibility of Dallas Countys cleaning

contractor.

6.1.1.1.Facilities Management oversees contract compliance; questions regarding thecleaning contract should be referred to Institute Administration who will

consult with Facilities Management contract administration staff.6.1.2.Biological decontamination and related cleaning is the responsibility ofknowledgeable Institute staff working in or assigned to an area.

6.2.Biological Work Areas6.2.1.Each area or laboratory in which potentially infectious materials exist must develop

a housekeeping checklist or standard operating procedure.6.2.2.The checklist/procedure will take into consideration the location within the facility,

the type of surface to be cleaned, type of soil present, and tasks or procedures

performed in the area.6.2.3.Biologically contaminated work surfaces must be decontaminated as soon as

feasible when contamination occurs.

6.2.4.Where possible, biological materials should be handled on impervious surfaces orsurfaces covered with disposable covering.

6.2.5.All bins, pails, trashcans, and similar receptacles must be inspected anddecontaminated on a regular basis as specified in the checklist/procedure.

6.3.Cleaning Procedures6.3.1.Gloves should be worn while cleaning and disinfecting.6.3.2.When gross contamination is present, it must be removed with soap and water,

where appropriate, prior to disinfection.6.3.3.Chemical Decontamination and Disinfection of Biologicals

6.3.3.1.Various chemical products are available to decontaminate work surfaces.6.3.3.2.Read the container label and follow instructions for use and appropriate PPE.

6.3.3.2.1.Different chemical products have varying activity against pathogens.6.3.3.2.2.Most chemical decontaminants require contact time with the surface to

be maximally effective.

6.3.3.2.3.Commercial disinfectant products should be registered with the EPA.6.3.3.3.High Level Disinfection (sporocides) These products kill all

microorganisms except high numbers of bacterial spores; they typically require

a 5 10 minute exposure time to be maximally effective. These products

typically contain aldehydes, hydrogen peroxide, or paracetic acid.6.3.3.4.Intermediate Level Disinfection (tuberculocides) These products kill M.

tuberculosis var. bovis and all vegetative bacteria, fungi, and most viruses.

Dwell time for maximum effectiveness is 20 minutes. These products

typically contain phenolics, iodophores, chlorine compounds (10% bleach),and alcohols. This is the level of disinfectant required for most activities at the

Institute.

6.3.3.5.Low Level Disinfection (routine hospital grade germicides) Theseproducts kill most vegetative bacteria and some fungi but not M. tuberculosis

var. bovis. Dwell time for maximum effectiveness is 20 minutes. These

products typically contain quartenary ammonium compounds.6.3.4.Use of Bleach as a Routine Disinfectant





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6.3.4.1.Bleach solutions are the primary disinfectant used at the Institute.6.3.4.2.Clean the area of gross biological contamination using soap and water, apply

bleach solutions. Bleach solutions should remain on a surface for

approximately 5 minutes to obtain maximal effectiveness.6.3.4.2.1.Diluted bleach solutions must be made fresh daily.6.3.4.2.2.

10% bleach solution6.3.4.2.2.1.Use 10% bleach to clean areas with gross biological

contamination; a 5 minute dwell time is tuberculocidal.

6.3.4.2.2.2.Add cup of household regular (not scented) bleach to 1 gallonof water; or

6.3.4.2.2.3.Add 1 tablespoon of household regular bleach to 1 quart (or 4cups) of water.

6.3.4.2.2.4.It may be useful to have a spray bottle made fresh daily availablefor routine use.

6.3.4.2.3.General surface disinfection6.3.4.2.3.1.Use a 1% (1:100 dilution) bleach solution.6.3.4.2.3.2.

Add 1 tablespoon of household (non-scented) bleach to 1 gallon ofwater.

6.3.4.3.Caution6.3.4.3.1.Bleach vapors can cause irritation to the respiratory system and contact

with bleach can cause irritation to skin.

6.3.4.3.2.The stronger the bleach solution and the greater the volume of bleachused, the more PPE is needed to safely work with bleach.

6.3.4.3.3.Use bleach solution with adequate ventilation.6.3.4.3.4.Wear gloves and fluid resistant garment.6.3.4.3.5.For large volumes or high concentration bleach, wear face shield or

goggles to protect against a chemical splash.

6.4.Decontamination of Personal Protective Equipment6.4.1.Reusable personal protective equipment (e.g. rubber boots, heavy-duty neoprene

gloves, etc.) must be cleaned and decontaminated as soon as feasible after

contamination with potentially infectious materials and/or on a regular schedule

which should be included in the housekeeping checklist/procedure.6.4.2.Reusable items that cannot be cleaned in the area in which they are used must be

placed in a sealed biohazard bag and transported to the washing/decontamination

area (such as the decomp autopsy room); this includes items used in the field.6.4.3.Reusable items must be washed with soap and water and disinfected with bleach

solution or other disinfectant.

6.5.Decontamination of Vehicles6.5.1.All items with potential biological contamination (such as used PPE and evidence

with actual or suspected biological contamination) must be placed in biohazard bags

or other plastic bags which have been marked with a biohazard symbol prior to

being placed into a vehicle.6.5.1.1.Usually these items should be placed into the trunk.

6.5.2.All personal protective equipment must be removed prior to entering the passengercompartment of the vehicle.

6.5.3.If any part of the vehicle should become contaminated with a biological material,Institute of Forensic Sciences 10 Biological Exposure Control Plan




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the contaminated material must be removed as soon as possible with soap and waterand the area disinfected.

6.5.4.The cargo compartment of the Morgue van should be washed with soap and waterand disinfected on a routine schedule.

7.Shipping and Mailing Biologicals

7.1.Biological materials transported, shipped, or mailed outside the Institute must be labeledas a biohazard and/or placed into a biohazard bag prior to packaging for shipping or

transport

7.2.Biological specimens should be shipped in appropriate shipping containers.7.2.1.Liquid samples must be double bagged and absorbent placed win the secondary

container; the shipping container must be hard sided.

7.2.2.Contact the shipper for additional information.8.Biological Spills

8.1.For a suspected biological exposure, follow procedures in the Blood/Body FluidExposure Protocol notebook located in the Field Agent Office.

8.2.Alert co-workers to request assistance and avoid their exposure.8.3.Notify supervisor.8.4.Define and isolate the contaminated area.8.5.Put on appropriate PPE.

8.5.1.Gloves and fluid resistant garment are minimal PPE.8.5.2.Where splash, spray, or splatter of liquids or flaking of dried material may

reasonably be expected, use face shield or goggles, mask, shoe covers, and/or moreextensive fluid resistant clothing.

8.6.Remove glass and solid materials with forceps or scoop. Never remove broken glassfrom a biological spill with hands.

8.7.Apply absorbent towels to the spill; remove bulk material and reapply towels if needed.8.8.Apply disinfectant to towel surface to decrease spatter and splashing. Allow adequate

contact time (5 minutes when using 10% bleach solution).8.8.1.Remove towel.8.8.2.Disinfect again.8.8.3.Clean with alcohol or soap and water.8.8.4.Dispose of materials in a leak proof, labeled biohazard container.

8.8.4.1.If chemicals are also involved in the spill; choose a proper disposal methodfor both types of hazards.

9.Regulated Biological Waste Disposal9.1.Regulated biohazard waste is described in 30 TAC Sections Part 1 Chapter 330

Subchapter Y.

9.1.1.Regulated biohazard waste cannot be disposed in the regular trash.9.1.1.1.Most regulated biohazard waste at the Institute includes biological lab

specimens, human organs/tissues, and other materials in which the blood or





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other biological fluids pool, puddle, cake, or flake.9.1.1.2.In addition to the biological waste defined and regulated by TDH and TCEQ,

the Institute routinely handles all waste which has been exposed to potentially

infectious materials as a biohazard waste.9.1.1.2.1.Therefore, all gloves and other materials that come in contact with a

potentially infectious substance must be discarded in biohazard wasteboxes or sharps containers or decontaminated prior to reuse.9.2.All contaminated sharps must be discarded as soon as feasible in sharps containers

located as close to the point of use as feasible in each work area.

9.2.1.Sharps containers must not be overfilled.9.2.2.Prior to disposal, the container must be closed and the entire box placed into a

biohazard waste box.

9.3.Regulated waste other than sharps must be placed in appropriate containers that areclosable, leak resistant, labeled with a biohazard label or biohazard color code, andclosed prior to removal.

9.3.1.Do not overfill or pack down biological waste.9.3.2.

If free flowing liquids are expected to be a part of the waste stream, add anadsorbent such as vermiculite to the bottom of the plastic bag prior to adding waste.

9.3.3.If outside contamination of the regulated waste container occurs, it must be placedin a second container that is also closable, leak-proof, labeled with a biohazard labelor biohazard color code, and closed prior to removal.

9.4.Dallas County contracts with a licensed biological waste vendor who is responsible fortransporting and disposing of regulated biological waste in accordance with federal,

state, county, and local requirements.

10.Laundry Procedures10.1.Although soiled linen may be contaminated with pathogenic microorganism, the risk of

disease transmission is negligible if it is handled, transported, and laundered in a mannerthat avoids transfer of microorganisms to personnel and the environment.

10.2.Institute Laundry10.2.1.Biologically contaminated personal clothing including scrubs and lab coats may

not be taken home to be laundered; these items must be laundered at or by the

Institute.

10.2.1.1.Scrubs are not considered PPE.10.2.2.Reusable PPE provided by the Institute must be cleaned/laundered at or by the

Institute and may not be taken home to be cleaned/laundered.

10.2.3.Laundry services are provided at the Institute.10.2.3.1.Routine laundry is not wet with biological contamination.

10.2.3.1.1.Therefore, laundry is routinely collected in standard laundry bags. Thebags must be closed prior to transporting upstairs to the laundry.

10.2.3.2.In the unusual situation when an item to be laundered is wet with biologicalcontamination, the item must be placed in a biohazard bag and sealed prior to

transporting to the laundry room.

10.2.3.2.1.The bag must be taken to the laundry room and washed as soon asfeasible.





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10.2.4.Laundry Procedure10.2.4.1.Gloves must be worn

SWIFS Environmental Health and Safety Program v2.0 (01.23.2008) 58 Pages

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