School of Nursing: Policy On Staff Infectious & Communicable Disease


School of Nursing: Policy On Staff Infectious & Communicable Disease

Unit Policy



The purpose of this policy is to outline the requirements for employees working in clinical environments who have professional contact/interaction with patients, clients, families and/or human subjects.

Scope of Applicability

This policy applies to all School of Nursing (SON) employees Including staff, student, temporary and intermittent temporary employees.


Policy Statement


Infectious/communicable diseases are common and may be a threat to staff and students of the SON. During the performance of clinical practice/research activities, staff may have contact with patients/human subjects who are HIV positive or who are infected with Tuberculosis (TB), Hepatitis B (Hep B), Acquired Immunodeficiency Disease (AIDS), or any number of other communicable diseases. This contact may expose staff to infectious agents that place that individual at risk for succumbing to a communicable disease or for unknowingly transmitting a communicable disease to other faculty, students, patients, family members, and/or human subjects. During pregnancy, the fetus may also be at risk.

To help protect the health and safety of its staff, as well as that of the public, the SON has specific requirements for all staff with employment responsibilities in a clinical environment that involves professional contact/interaction with patients, clients, families and/or human subjects. The requirements include:

  • Initial Environmental Health and Safety (EH&S) Clinical Orientation online session (one time only) and annual online session updates for Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Bloodborne Pathogens, and initial Tuberculosis (TB) screening and immunization review;
  • Annual TB screening;
  • Pre-exposure prophylactic immunization(s) against specified infectious/communicable diseases (based on findings from the immunization review and EH&S guidelines); and
  • Post-exposure prophylactic follow-up/treatment following exposure to specified infectious/communicable disease.

Initial Screening and Training Requirements

New staff members employed by the SON whose employment involves professional contact/interaction with patients, clients, families and/or human subjects are required to be designated as working in a clinical environment. The first activity that must be completed is the EH&S Clinical Orientation session.

Initial Environmental Health & Safety Clinical Orientation

To complete the one-time EH&S Clinical Orientation session online, go to the EH&S "Employee Orientation" webpage and select "Clinical". All staff will need their ONYEN or PID number. If you do not remember your PID number please contact the SON Human Resources office at (919) 843-6761.

Initial Tuberculosis (TB) Screening and Immunization Review

New staff members employed by the SON should discuss their responsibilities with their direct supervisor and answer two questions:

  1. Will the new employee work in a health care facility or need a UNCH ID card?
  2. Will the employee come in direct contact with blood? The answers to these two questions will be conveyed by the direct supervisor to the SON Human Resources Manager for entry into the NURSYS system.

If the answer to question 1 above is yes, then the staff member is required to contact the University Employee Occupational Health Clinic (UEOHC) at (919) 966-9119 to schedule an appointment for an immunization history review and to determine if another TB screening is needed. The new employee must bring documentation of immunization history to their UEOHC appointment. If the employee has had a recent TB screening (within the past year) the employee can also bring the following documentation to their UEOHC appointment: the date the TB skin test was administered, date read, and the results. A deferral of the required immunizations and screening for medical reasons may be granted if written documentation from a health care provider is presented to UEOHC.

If the answer to question 1 above is no, yet the employee will have potential exposure to patients or human subjects in home or community settings (but not in a health care facility), the following guidelines apply. For new employees who are funded on grants or contracts (non-state funds) the SON recommends that the program manager or Principal Investigator (or his/her designee) track the employees' immunization histories and annual TB screenings for their specific project. Frequently, employees have responsibilities on grants that require work in community settings, however, they maintain employment in other health care settings where TB screening and up-to-date immunizations are required. SON project managers/investigators with EH&S are responsible for maintaining records of TB screenings for their project staff who do not work in a health care facility or have a UNCH ID card but work with patients, clients or human subjects in various community settings.

In summary, initial screening and training requirements are met when new employees complete the EH&S Clinical Orientation, immunization review, and TB screening.

Annual Screening & Training Requirements

Staff who answer "yes" to the questions "Will the employee work in a health care facility or need a UNCH ID card?" need to complete the following screening and training requirements each year:

  • Tuberculosis screening test (at UEOHC)
  • Tuberculosis self study unit (online)
  • Healthcare/JCAHO Worker General Safety self study unit (online)

Staff who answer "yes" to the question "Will the employee come in direct contact with blood?" need to complete the following training requirements each year:

  • Bloodborne Pathogen Self Study Unit (online)

All self study units can be completed online on the EH&S website.

Monitoring Compliance

A change in work assignment, from non-contact to contact, during the academic year should be reported by the direct supervisor to the SON compliance office, so the monthly EH&S Compliance report can be updated appropriately. The SON compliance office will request the completion of the appropriate annual screening/training by the staff to insure compliance.

EH&S sends notices to continuing staff thirty days in advance of the need to update required immunizations/testing including subsequent Hep B Vaccine injections. EH&S maintains a current and accurate database of staff compliance with SON clinical health requirements and sends notices to staff when they have not completed the initial requirements, or have fallen out of compliance. Staff may also visit the EH&S website to gain information about their compliance status.

Staff with ongoing contact are required to complete the annual health and safety compliance prior to the expiration date of each requirement.

Newly employed and continuing staff who fail to meet University and SON health and safety training and immunization requirements shall be reported to the appropriate SON administrator for follow-up action, and shall be temporarily withdrawn from client contact until requirements are met, and the consequences of not meeting health and safety training and immunization requirements will be considered in the staff member's annual review.

Staff needing additional information regarding these requirements may contact SON Human Resources at (919) 843-6761 for assistance.

Post-Exposure Prophylactic Follow-Up and Treatment

The EH&S Environment, Health and Safety Manual provides guidance for post-exposure prophylactic follow-up and treatment. Call UEOHC at (919) 966-9119 immediately after any blood/body fluid exposure. If the exposure occurs during non-business hours, proceed immediately to the nearest emergency room.

Blood/body fluid exposure care

Following established protocols, the clinic staff provides immediate management for employees who have experienced blood/body fluid exposure. It is the responsibility of the exposed employee and/or the exposed employee's supervisor to contact the clinic immediately in the event of an exposure.

Other communicable disease exposure care

Management of employees with work-related exposure to tuberculosis or other communicable diseases.

Workers' compensation treatment and case management

For treatment of work-related injuries and illnesses, the UEOHC will provide initial/on-going care and arrange for any necessary services including referrals to specialists and rehabilitation services. Lost work-time or work restrictions will be coordinated by the UEOHC. The UEOHC will provide case management services until the employee has returned to their previous level of functioning.


Staff working in clinical settings outside of the University of North Carolina at Chapel Hill are required to comply with agency specific policies prior to initiating work with the agency.

Related Requirements

Contact Information

Policy Contact

Lisa Miller, Associate Dean for Administration

Other Contacts


Important Dates

  • Effective Date and title of Approver: 11/27/2001 approved by the Administrative Council
  • Revised: 4/19/2005 by the Dean's Cabinet and approved by the Executive Committee on 5/9/2005


Article ID: 132385
Thu 4/8/21 9:30 PM
Wed 7/5/23 11:31 AM
Effective Date
If the date on which this document became/becomes enforceable differs from the Origination or Last Revision, this attribute reflects the date on which it is/was enforcable.
02/11/2021 3:28 PM
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
Title of the person who is primarily responsible for issuing this policy.
Associate Dean, Administrative Services
Last Review
Date on which the most recent document review was completed.
07/05/2023 12:00 AM
Last Revised
Date on which the most recent changes to this document were approved.
04/14/2020 11:13 AM
Next Review
Date on which the next document review is due.
07/05/2026 12:00 AM
Date on which the original version of this document was first made official.
07/17/2018 12:00 AM
Responsible Unit
School, Department, or other organizational unit issuing this document.
School of Nursing