Claims Bodily Fluids Work Exposure Form
This instruction has been prepared by the Industrial Commission of Arizona solely to provide general guidance concerning the topics addressed herein. The information contained in this document is not intended to create rights or obligations and is not intended to expand, limit, or in any manner modify applicable law, statutes or rule. The information contained in this document is believed to be accurate based on the information available as of January 2015. Page 1 Revised January 2015
SIGNIFICANT EXPOSURE UNDER THE ARIZONA WORKERS’ COMPENSATION ACT
In 2011, the Arizona Legislature amended the reporting requirements for a possible significant exposure to Methicillin-Resistant Staphylococcus Aureus (MRSA), which are found in Arizona Revised Statutes section 23-1043.04(B). Effective July 20, 2011, employees must report a possible significant exposure to MRSA that occurs at work to their employers within thirty calendar days after the possible significant exposure. Employees must also be diagnosed with MRSA within fifteen days after the employee reports the possible significant exposure to their employer(s). Employees should use the updated form to report significant exposure. Employers must display the updated Notice to Employees (poster) titled “Work Exposure to Methicillin-Resistant Staphylococcus Aureus, Spinal Meningitis or Tuberculosis (TB).”
What is a Significant Exposure Under the Arizona Workers’ Compensation Act?
A report of significant work exposure to blood, bodily fluids, or other potentially infectious materials may be made by completing a form that reports this exposure. This form may be obtained from your employer or on the Industrial Commission of Arizona website at http://www.azica.gov. But, what is a “significant exposure”? In some instances, such as an exposure to bloodborne pathogens, you may not know if the blood, bodily fluids or other material to which you are exposed is infectious. In other instances, such as an exposure to Tuberculosis, MRSA, or Meningitis, you may know if the exposure is “significant” based on the symptoms of the person to whom you are exposed. Understanding the pathogens involved and how they are spread will help you answer the question, but if you have any concern as whether you should report the exposure, then you should “play it safe.” Talk to your doctor, talk to your HR Department, or simply use this form to report what you believe to be a significant exposure. For more information regarding the requirements for filing a workers’ compensation claim for a significant work exposure, and the presumptions that are available to certain classes of employees, please read the posters that are required to be posted at your workplace that contain this information.
Bloodborne pathogens (“BBP”) are disease causing organisms such as human immunodeficiency virus (“HIV”), hepatitis B, or hepatitis C that may be present in human blood or bodily fluids that are considered “other potentially infectious material.” “Human Blood” includes human blood components and products made from human blood. “Other potentially infectious material” (“OPIM”) includes semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and any bodily fluid that is visibly contaminated with blood. Unless visibly contaminated with blood, these pathogens This document has been prepared by the Industrial Commission of Arizona solely to provide general guidance concerning the topics addressed herein. The information contained in this document is not intended to create rights or obligations and is not intended to expand, limit, or in any manner modify applicable law, statutes or rule. The information contained in this document is believed to be accurate based on the information available as of January 2015. Page 2 Revised January 2015
are not transferred through tears, saliva (except in dental procedures), or perspiration. An easier way to think about this is to remember that OPIM are bodily fluids that are intended to always remain inside the body, sexual fluids, and any human tissue that is intended to be covered by skin. A significant exposure to BBP may occur when you come into contact with blood or OPIM through a break or rupture in your skin (e.g., needlestick injury or you cut yourself with a sharp instrument contaminated with blood), or your mucous membranes (e.g. blood or OPIM gets in your eyes, nose, mouth, or you engage in sexual activity with an infected person). The CDC indicates that a human bite that breaks the skin should also be considered a significant exposure. Additional information on HIV and Hepatitis may be found at www.cdc.gov.
Tuberculosis (TB) is a contagious disease that spreads through the air. Only people who are sick with active TB disease in their lungs are infectious. When infectious people cough, sneeze, talk or sing, they propel TB germs, known as droplet nuclei, into the air. These germs can stay in the air for several hours, depending on the environment. While not normally transmitted within minutes or hours of sharing the same “airspace,” a person needs only to inhale a small number of the TB germs to be infected. You do not get TB by just touching the clothes or shaking the hands of someone who is infected. Tuberculosis is spread (transmitted) primarily from person to person by breathing infected air during close contact. A person infected with active TB may show general symptoms of unexplained weight loss, loss of appetite, night sweats, fever, fatigue, and chills. Other symptoms of TB of the lungs include coughing for 3 weeks or longer, coughing up blood, and chest pain. Additional information on TB can be found at www.cdc.gov.
Methicillin-Resistant Staphylococcus Aureus, also known as MRSA, is a potentially dangerous type of staph bacteria that has become resistant to one family of common antibiotics. MRSA is a contact risk. You can get MRSA through direct contact with an infected person, sharing personal items (such as towels or razors that have touched infected skin) or touching shared items (clothing, door knobs, workout benches, etc.). Most staph skin infections, including MRSA, appear as a bump or infected area on the skin that may be red, swollen, painful, warm to the touch, full of pus or other drainage, and accompanied by a fever. Many people describe it as looking like a spider bite. Additional information on MRSA can be found at www.cdc.gov.
Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges. The inflammation is usually caused by an infection of the fluid surrounding the brain and spinal cord. Meningitis is also referred to as spinal meningitis. Meningitis may develop in response to a number of causes, but it is usually caused by bacteria or viruses. Bacterial meningitis is spread from person to person through the exchange of respiratory and throat secretions, normally occurring through coughing, kissing, and sneezing. It is not spread through casual contact or by simply breathing the air where a person This document has been prepared by the Industrial Commission of Arizona solely to provide general guidance concerning the topics addressed herein. The information contained in this document is not intended to create rights or obligations and is not intended to expand, limit, or in any manner modify applicable law, statutes or rule. The information contained in this document is believed to be accurate based on the information available as of January 2015. Page 3 Revised January 2015 with meningitis has been. It is considered a “heavy droplet” contact risk, similar to a cold, but not nearly as contagious as the cold. Viral meningitis is also spread from person to person through respiratory secretions (saliva, sputum, or nasal mucus) of an infected person. It can also be spread from person to person through fecal contamination (which can occur when changing a diaper or using the toilet and not properly washing hands afterwards). An adult infected with meningitis may have a high fever, severe headache, stiff neck, sensitivity to bright light, sleepiness or trouble waking up, nausea, vomiting, or lack of appetite. Bacterial meningitis can be more severe and immediate care can be important. Additional information on meningitis can be found at www.cdc.gov.
This form can be used to report significant exposure. Please follow the instructions on the form very carefully.