School of Nursing: Faculty Health and Safety Compliance and Occupational Health Requirements


School of Nursing: Faculty Health and Safety Compliance and Occupational Health Requirements

Unit Policy



Employment at the University is contingent upon faculty meeting and maintaining essential compliance requirements. In addition, the many clinical agencies with whom School of Nursing (SON) faculty engage as part of their teaching, research, or service mission(s) have policies that must be adhered to as per contractual agreement. These clinical site requirements are in addition to University employment-related policies. Clinical agency policies are subject to change often with little notice. The purpose of these policies is to both protect the faculty member as well as the public with whom the faculty member interacts as part of their work as a University employee.

Scope of Applicability

Faculty employed by the School must achieve compliance with all health, safety, and legal requirements at the time of hire and prior to any contact with students, clients, or research subjects. Continuing faculty must maintain full compliance with all renewable requirements throughout their tenure with the School. Faculty adherence to these compliance requirements is expected regardless of the type of teaching, practice, service, or research assignment in any particular term. All faculty who enter any clinical facility on a regular basis in their role as a UNC SON faculty member regardless of the role in which they are engaging at the time (teaching, research, service) must adhere to that agency’s compliance requirements.

This policy also applies to graduate/doctoral students who are hired as Teaching Fellows in the SON.


Policy Statement

Compliance requirements are ever-evolving and expanding. They include initial employment related requirements as well as recurring employment related requirements that require regular monitoring. For example, they range from holding a valid, current, and unrestricted RN license to practice in the state of North Carolina to policies related to infections/communicable diseases that may be a threat to those with whom the faculty member comes into contact. For faculty who are providing either Direct or Indirect Clinical Supervision of students, please refer to the list of current Faculty Clinical Agency Compliance Requirements, see the Consortium for Clinical Education and Practice (CCEP) website.

Additional, supplementary requirements may be contractually mandated by a clinical agency where a faculty is practicing, supervising students, engaging in service, or conducting research. These additional elements are required and non-negotiable.

Any faculty member who fails to attain and maintain the required full compliance during their period of SON employment will not be allowed to assume or continue their academic responsibilities. Faculty who fail to maintain currency of all requirements will be removed from all clinical agency, client/subject, and student contact. Failure to maintain full compliance or tardiness in meeting requirements will both be reported to the Associate Dean for Academic Affairs for action and will attain a ‘Not Meets Expectations’ on their annual evaluation, meaning the faculty will be ineligible for merit considerations in the year in which the lapse occurred.

Ensuring Faculty Health

Infectious/communicable diseases are common and may be a threat to faculty of the School of Nursing. During the performance of clinical practice/research activities, faculty may have contact with patients/subjects with various infections such as bloodborne transmitted disease (e.g., Hepatitis B [HBV], Hepatitis C [HCV], Human immuno-deficiency virus [HIV; AIDS]), airborne transmitted disease (e.g., tuberculosis[TB], measles, varicella), droplet transmitted disease (e.g., influenza, pertussis, mumps), and contract transmitted disease (e.g., methicillin-resistant Staphylococcus aureus). This contact may expose the faculty member to infectious agents and may result in transmitting an infectious disease to others. During pregnancy, the fetus may also be at risk depending on the infection (e.g., Varicella).

To help protect the health and safety for all, the School of Nursing requires:

  1. Initial infectious disease screening;
  2. Pre-exposure prophylactic immunization against specified infectious/communicable diseases; and
  3. Post-exposure prophylactic follow-up/treatment following exposure to specified infectious diseases such as HBV, HIV, and tuberculosis.

Compliance Repositories

The School of Nursing is required to use the University Employee Occupational Health Clinic (UEOHC) for faculty compliance monitoring and tracking. UEOHC will also maintain HIPAA, licensure and certification data, and CPR training status.

Non-health related, agency-specific compliance documents will be housed in an on-line vendor database. Each faculty member will have their own account, funded by the SON, where documents will be stored.

Use of these two repositories will facilitate review and monitoring as well as allow for timely response when an agency audits for faculty compliance.

Faculty Responsibilities

Faculty are responsible annually for reviewing the status of their employment and health requirements via the UEOHC portal. They are responsible for ensuring all immunizations are current and that verification of immunization, HIPAA training, and CPR card is available in the UEOHC portal. Faculty who are nurses are required to maintain their RN License in the UEHOC database. Attestation of meeting these requirements is no longer permitted.

Faculty will be accountable for completing all clinical agency-required documents housed in the online vendor site. The vendor will not be reviewing these documents for accuracy or completion. Faculty must have completed all required training by deadlines to avoid jeopardizing student learning.

Upon hire or upon assignment to teach a clinical component of a course, the Academic Associate Dean or hiring individual will notify SON Human Resources (HR) whether or not surveillance via the UEOHC is required based on job responsibilities. In turn, SON HR will ensure notification to the UEOHC system. The faculty member will be informed of their specific clinical agency assignment by the course coordinator. Faculty are responsible for meeting all clinical agency training, compliance, and competency requirements prior to the start of any clinical rotation or prior to any regular engagements in a Health Care Facility. Additionally, clinical agencies require other documents to be completed in addition to clinical competency requirements. These agency-specific required documents must be completed prior to each semester and will be found in the on-line vendor’s site. Failure to maintain currency will result in disciplinary action. There is no grace period following an expiration date. It is the sole responsibility of each faculty to maintain a current knowledge of their compliance standing. The faculty member is reminded to maintain a personal file of all compliance-related documents and certificates.

Faculty who teach in the Undergraduate program will be required to have a North Carolina Board of Nursing (NCBON) Curriculum Vitae (CV) on file at the Board. See the "Education Forms" section of the North Carolina Board of Nursing's website for details on that CV format. Faculty are required to maintain their own NCBON CV and to provide the Associate Dean/Undergraduate Division and Program with a current version. These CVs are stored in the faculty personnel files in the Undergraduate Division Office.

School of Nursing’s Responsibilities

The SON provides the necessary information to faculty for achieving and maintaining compliance via a secure, PID authenticated database that is accessible on the Web. The UEOHC database is designed to enable faculty to meet the health-related compliance requirements for the School/University as well as all clinical agencies. The School also contracts with an on-line vendor to ensure that faculty have a web-based solution to agency specific compliance documents.

The SON Office of Administrative Services (OAS) has primary responsibility for obtaining initial and continuing employment related documents, such as employment criminal background check and verification of RN license (if applicable). Faculty who do not meet these initial requirements will be reported by SON HR Office to the Associate Dean for Academic Affairs and the appropriate Academic Associate Dean.

For supplemental requirements, the SON Office of Academic Affairs (OAA)/Clinical Support Division has primary responsibility for obtaining and maintaining information regarding clinical agency requirements in the on-line vendor’s site. The course coordinator will direct clinical faculty to this on-line vendor the semester prior to the implementation of the course as part of the planning process. This must be completed prior to the start of the semester in which the course is being offered.

The School is a member of the Consortium for Clinical Education and Practice (CCEP) of Wake Area Health Education Center (AHEC). The CCEP identifies, prioritizes, and addresses clinical placement issues for nursing students in the Triangle Region of North Carolina. The SON adheres to all CCEP standards and policies. The School is required to notify all faculty and students when there are changes to CCEP policies and policies of other clinical agencies with whom the SON has a contractual affiliation agreement. This will occur via email notification.

Employment-required Health and Safety Requirements

  • Personal health/accident insurance coverage
  • Background check based on legal name, date of birth and employee provided SSN and covering the lesser period of the past seven years to include a search of:
    • all geographic addresses, both domestically and internationally, associated with the faculty member’s complete residential history, places of employment, and educational institutions the faculty has attended in the past seven years;
    • all felony and misdemeanor charges and convictions (except minor traffic related violations);
    • a national Sexual Offender/Predator Database check; and
    • a check against the Office of the Inspector General's List of Excluded Individuals/Entities (LEIE) and the General Services Administration's Excluded Parties list (EPLS).
  • Initial Environmental Health & Safety (EHS) Clinical Orientation
    • To complete this one-tme orientation session go to the EHS Employee Orientation webpage and select 'Clinical'. This is a PID/ONYEN protected site.
  • Initial TB Screening and Immunization Review:
    • At the time of hire, the hiring manager will determine if each new faculty/TF will:
      • 1. Work in a health care facility;
      • 2. Have the potential to come into contact with blood?
      If the answer to either/both is 'yes', then the new Employee will be directed to contact the UEOHC at (919) 966-9119 to schedule an appointment for an immunization history review and to determine addition immunizations needed/need for TB screen.The employee should take all immunization documentation with them to their appointment at UEOHC. These faculty will be entered into the EHS Immunization Surveillance Program.
    • If the answer to #1 above is 'No' for health care facility, but 'yes' for home or community settings, the guidelines above apply. These guidelines apply to all faculty/TF or RA's engaged in research as well.

Continuing Compliance Requirements

  • ALL documentation must be submitted for official review through UEHOC.
Clinical Agency Compliance Related Health Requirements:
Clinical Agency Compliance Related Safety Requirements
  • AHA-BLS Certification or PALS, renewal required every two years; and
  • Annual OSHA training/testing - required modules: blood and air-borne pathogens, tuberculosis and infection control, and JCAHO general safety.
Compliance-Related Legal Requirements
  • SON Confidentiality Statement;
  • Annual HIPAA training/testing: general privacy module only;
  • Unrestricted RN License (if applicable);
  • School of Nursing: Social Media Policy;
  • AHEC Core Orientation.
Other Compliance-Related Policies

Contact Information

Policy Contact

Peggy Wilmoth, Executive Vice Dean

School of Nursing


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Article ID: 132362
Thu 4/8/21 9:29 PM
Mon 3/4/24 2:48 PM
Responsible Unit
School, Department, or other organizational unit issuing this document.
School of Nursing
Issuing Officer
Name of the document Issuing Officer. This is the individual whose organizational authority covers the policy scope and who is primarily responsible for the policy.
Issuing Officer Title
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Senior Associate Dean for Academic Affairs
Next Review
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07/22/2024 12:00 AM
Last Review
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07/22/2022 12:00 AM
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01/05/2021 10:37 AM
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01/05/2021 10:37 AM
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11/05/2019 8:59 AM