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Operating Policy and Procedure

HSC OP: 40.01 , Health Surveillance Program for ÍâÍøÌìÌÃ

PURPOSE: The purpose of this policy is to establish and maintain a comprehensive Health Surveillance Program at Texas Tech University Health Sciences Center (ÍâÍøÌìÌÃ) that protects the health and safety of learners, trainees, employees, volunteers, and others engaged in ÍâÍøÌìÌÃ-sponsored activities. The Program is designed to support primary prevention, early detection, timely response, and ongoing monitoring of occupational and exposure-related health risks across clinical, research, and educational settings.

This Health Surveillance Program aligns with standards and recommendations set forth by the Centers for Disease Control and Prevention (CDC), the Texas Department of State Health Services (DSHS), the U.S. Public Health Service (PHS), and the Occupational Safety and Health Administration (OSHA), as well as the Texas Administrative Code (TAC), including §§96 (Bloodborne Pathogen Control), 97 (Communicable Diseases), and 99 (Occupational Diseases).

Through coordinated education, health screening, immunization, exposure management, and surveillance protocols, this Program is an essential component of ÍâÍøÌìÌÃ’s institutional commitment to maintaining a safe and compliant academic healthcare environment.

SCOPE: This Program applies to ÍâÍøÌìÌà campuses, educational sites, and related clinical facilities.

REVIEW: This HSC OP and attachments will be reviewed on June 1 of each odd-numbered year (ONY) by the Executive Director of the Office of Institutional Health and Wellness, Academic Affairs and Curriculum Committee, and Academics Council.

POLICY/PROCEDURE:

1. Program Administration: The ÍâÍøÌìÌà Health Surveillance Program is administered by the Office of Institutional Health and Wellness, which provides strategic oversight, process/procedure development, and coordination of all health surveillance activities across the institution. This includes processes related to immunizations, tuberculosis screening, exposure management, animal research, occupational health, and compliance with applicable regulatory standards.

The Office collaborates closely with designated Health Surveillance Units within each ÍâÍøÌìÌà campus, site, school, and relevant operational unit to implement program recommendations tailored to local needs while ensuring consistency with institutional policies and public health guidelines.

The administrative structure and reporting lines of the Health Surveillance Program are detailed in Appendix A.

All operational details, including forms, processes, deadlines, contact information, program costs/fees, and other procedural guidance, are maintained by the Office of Institutional Health and Wellness and are accessible via the program website: /institutional-health/

2. Covered Individuals: The Health Surveillance Program applies to individuals at ÍâÍøÌìÌà whose assigned duties involve a risk of occupational or educational exposure to infectious agents, hazardous biological or chemical materials, laboratory animals, or other workplace health risks. Participation in the program is based on the nature of an individual’s responsibilities, not their job title, and includes those involved in clinical care, laboratory research, and other activities that present potential health hazards.

a. Individuals with Patient-Facing Responsibilities: This category includes faculty, staff, administrators, residents, fellows, postgraduates, learners, and volunteers who have a reasonable potential for exposure to patients or infectious materials in the course of their duties. Individuals covered may be directly involved in patient care or may work in patient care environments where exposure to infectious agents is possible. Participation in the Health Surveillance Program for this group includes compliance with required immunizations, tuberculosis screening, education related to infection prevention, and follow-up after exposure events.

b. Individuals Involved in Animal or Laboratory Research: Individuals who work with live animals, unfixed animal tissues or fluids, or infectious agents in laboratory settings are also covered under the Health Surveillance Program. This includes those conducting research or teaching through the Laboratory Animal Resources Centers (LARCs) or in any facility where animal contact or biological risk is present. These individuals are required to participate in the Animal Occupational Health and Safety Program, which may include baseline health evaluations, species-specific immunizations or titers, laboratory safety training, and periodic medical surveillance based on the risks associated with their research activities.

c. Individuals with Occupational Exposure Risk Outside of Clinical or Animal Roles: This category includes wage employees, staff, and volunteers whose responsibilities may involve exposure to hazardous chemicals, respiratory risks, physical hazards such as noise or radiation, or other occupational health risks not directly related to patient care or animal handling. Depending on the nature of their work, these individuals may be required to undergo hazard-specific medical evaluations, such as respirator medical clearance, audiometric testing, or monitoring for exposure to substances like formaldehyde or cytotoxic drugs. Participation requirements are determined based on job duties and aligned with institutional policies and regulatory standards.

3. Medical and/or Religious Exemptions: ÍâÍøÌìÌà recognizes that some covered individuals may seek exemption from certain health surveillance requirements, including immunizations, based on valid medical contraindications or sincerely held religious beliefs. ÍâÍøÌìÌà does not provide immunization exemptions; however, we do accept official medical and religious exemption documentation as recognized by the State of Texas.
 
Medical exemption requests may require documentation from a licensed healthcare provider detailing the contraindication or precaution. Religious exemption requests must include a statement affirming the sincerely held religious belief or practice that conflicts with the health requirement.
 
All exemption requests will be reviewed by the Office of Institutional Health and Wellness in accordance with applicable laws, institutional policies, and safety considerations. Approval of exemptions may be subject to limitations and additional risk mitigation measures, such as reassignment or enhanced personal protective equipment, to ensure the safety of the individual and the community.
 
Covered individuals are encouraged to contact the Office of Institutional Health and Wellness with any questions regarding exemptions or the process.

4. Health Program Surveillance Program Components: The ÍâÍøÌìÌà Health Surveillance Program consists of core components designed to prevent, detect, and respond to occupational health risks associated with clinical, research, and educational activities. Each component is grounded in regulatory guidance and public health best practices, and collectively they ensure a comprehensive approach to institutional health and safety.

a.Tuberculosis Surveillance, Screening, and Clearance: Tuberculosis surveillance for covered individuals is conducted in accordance with the most current guidelines issued by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), including the 2019 publication Tuberculosis Screening, Testing, and Treatment of the U.S. Health Care Personnel. The goal of this surveillance is to prevent TB transmission in clinical, academic, and laboratory settings by identifying individuals with latent TB infection (LTBI) or active disease.

All covered individuals should complete baseline TB screening prior to the start of their employment, training, or academic program. Screening typically includes an Interferon-Gamma Release Assay (IGRA) blood test (e.g., T-SPOT or QuantiFERON), unless otherwise indicated based on medical history or prior testing. Annual TB screening and/or testing is recommended for certain populations, such as those in high-risk settings, while others may undergo symptom-based screening or periodic reassessment based on risk classification.
 
Individuals with a history of positive TB testing must provide documentation of previous results and may be required to complete a TB symptom questionnaire and/or chest radiograph. Any positive findings are evaluated by the Office of Institutional Health and Wellness or referred to appropriate clinical providers for follow-up and clearance prior to participation in patient care or laboratory work.

b. Immunization Compliance and Clearance: Covered individuals should comply with the CDC’s Healthcare Personnel Vaccination Recommendations and the Texas Administrative Code (TAC) §97.64, which outlines recommended immunizations for students enrolled in health-related and veterinary training programs. This recommendation applies to all ÍâÍøÌìÌà students who participate in clinical or laboratory experiences involving direct patient contact. It includes, but is not limited to, medical students, residents, fellows, nursing students, and others enrolled in training programs within health science facilities, regardless of student classification, course load, or program duration.
 
Compliance includes submitting appropriate documentation of recommended vaccinations, immunity via serologic testing (when applicable), and booster doses as needed. The Office of Institutional Health and Wellness oversees the review and validation of immunization records and maintains secure documentation for institutional and regulatory purposes.

c. Exposure Management: ÍâÍøÌìÌà provides coordinated institutional management of exposure events involving bloodborne pathogens, potentially infectious body fluids, laboratory or research materials, and other occupational biohazards. This includes, but is not limited to, percutaneous injuries (e.g., needlesticks), mucous membrane exposure, inhalation of aerosols, or direct contact with non-intact skin. The approach is guided by the latest recommendations from the Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA), the Texas Administrative Code (TAC), and the Texas Department of State Health Services (DSHS).
 
Timely reporting of exposure incidents is essential for initiating appropriate post-exposure evaluation, treatment, and follow-up. Procedures for reporting exposures, expected response timelines, and contact information for designated campus health surveillance units are outlined by the ÍâÍøÌìÌà Office of Institutional Health and Wellness. This information, along with forms and step-by-step guidance, is available at /institutional-health. 

d. Animal/LARC Occupational Health Program: The Animal/LARC Occupational Health Program protects both personnel and animals by offering comprehensive health surveillance and clearance procedures tailored to risks in animal research settings. This program adheres to authoritative guidance from the National Research Council’s Occupational Health and Safety in the Care and Use of Research Animals (1997), the Guide for the Care and Use of Laboratory Animals, the CDC/NIH Biosafety in Microbiological and Biomedical Laboratories, and other pertinent resources. 
 
All ÍâÍøÌìÌà faculty, staff, students, trainees, volunteers, and visitors who work with live vertebrate animals, unfixed tissues, body fluids, waste, or equipment in animal housing or LARC facilities are required to enroll in the program. Enrollment includes a health questionnaire, risk-based medical evaluation, recommended species- or agent-specific immunizations or titers, respiratory fit testing (when appropriate), allergy assessment, and safety training.
 
The program follows a risk-tiered model: individuals with minimal animal contact are offered voluntary enrollment and hazard education, while those with direct, frequent, or high-risk exposure (e.g., non-human primates, ABSL‑2/‑3 work) undergo mandatory evaluation and follow-up. Periodic reassessment, typically annual or prompted by changes in duties or health conditions, ensures ongoing clearance.
 
Supervisors and researchers are responsible for alerting the Office of Institutional Health and Wellness to new personnel and exposure changes. The Office of Institutional Health and Wellness maintains records and tissue clearances before work may commence. Comprehensive procedures, timelines, forms, and contact information are available on the ÍâÍøÌìÌà Institutional Health & Wellness website.

e. Occupational Health: The Occupational Health component of the ÍâÍøÌìÌà Health Surveillance Program addresses the identification, evaluation, and management of workplace health risks for employees, students, and volunteers who face potential exposure to chemical, biological, physical, or ergonomic hazards outside of direct patient care or animal research. This program ensures compliance with applicable federal and state regulations, including the Occupational Safety and Health Administration (OSHA) standards (such as the Bloodborne Pathogens Standard, Hazard Communication Standard, and Respiratory Protection Standard), and Texas Administrative Code requirements.

Occupational Health services include pre-placement and periodic medical evaluations, respirator fit testing and clearance, exposure monitoring, and post-exposure follow-up for hazardous substances. The program also supports early identification of work-related illnesses and facilitates interventions to maintain workplace safety and health.

The Office of Institutional Health and Wellness collaborates with Environmental Health and Safety, department supervisors, and affected personnel to implement surveillance protocols aligned with regulatory requirements and institutional policies. Detailed procedures, reporting requirements, and program resources are accessible through the Institutional Health and Wellness website. 

f. Respiratory Fit Testing: Respiratory fit testing is a critical component of the ÍâÍøÌìÌà Health Surveillance Program and is recommended for all employees, students, and volunteers who are assigned duties requiring the use of tight-fitting respirators. This includes personnel working in environments where exposure to airborne hazards such as infectious aerosols, chemical vapors, or particulates is possible.

Fit testing is conducted in accordance with an individual’s clinical site requirements to ensure that respirators provide an effective seal and adequate protection. Both qualitative and quantitative fit testing methods can be utilized depending on the respirator type and job requirements.

Individuals who require fit testing must complete an initial fit test prior to respirator use and undergo additional retesting or more frequent testing as required by a clinical site if there are changes in facial structure, weight, or respirator model. The ÍâÍøÌìÌà Office of Institutional Health and Wellness coordinates fit testing services, maintains documentation of fit test results, and ensures compliance with regulatory standards.

Detailed procedures, scheduling information, and contact details for respiratory fit testing are available on the Institutional Health and Wellness website.

g. Education and Training: ÍâÍøÌìÌà is committed to providing comprehensive education and training to all covered individuals to promote awareness, prevention, and proper management of health risks. Education programs are tailored to specific roles and risk categories and include topics such as infection control practices, bloodborne pathogen exposure prevention, safe animal handling, respiratory protection, and chemical hazard awareness.

Training is delivered through a combination of in-person sessions, online modules, and written materials, ensuring accessibility and compliance with regulatory requirements from OSHA, CDC, and other relevant agencies. Covered individuals are required to complete initial training prior to engaging in clinical, laboratory, or animal-related activities, with periodic refresher training to maintain competency and update knowledge on evolving best practices.

Supervisors and program administrators are responsible for ensuring that personnel complete all mandatory education and training components and for documenting compliance. The Office of Institutional Health and Wellness coordinates curriculum development, delivery, and recordkeeping. Detailed training schedules, materials, and contact information are available on the Institutional Health and Wellness website.

h. Annual Health Surveillance Reporting: ÍâÍøÌìÌà is committed to monitoring and evaluating the effectiveness of its Health Surveillance Program through systematic collection and analysis of surveillance data. The Office of Institutional Health and Wellness compiles annual reports summarizing key metrics related to occupational exposures, immunization compliance, tuberculosis screening outcomes, respiratory fit testing, and other relevant health surveillance activities.

These reports provide insight into program participation, incidence of exposure events, follow-up outcomes, and trends that may impact workplace safety and health. The data support continuous quality improvement efforts, assist leadership in resource allocation, and ensure compliance with applicable regulatory requirements.

Aggregated surveillance data are reviewed annually by institutional leadership and relevant committees to identify areas for program enhancement and risk mitigation. Individual health information is maintained confidentially in accordance with privacy regulations and is not included in summary reports. In compliance with Texas Department of State Health Services (DSHS) requirements, ÍâÍøÌìÌà reports all needlestick and sharps injury incidents to the State of Texas.

Detailed information about data collection methodologies, reporting timelines, and program evaluation is available on the Institutional Health and Wellness website.

i. Clearance and Records Retention: The ÍâÍøÌìÌà Health Surveillance Program recommends that all covered individuals obtain appropriate health clearance prior to engaging in activities involving patient contact, animal research, or occupational exposure risk. Clearance is contingent upon successful completion and validation of required immunizations, tuberculosis screening, exposure management, and other relevant health assessments as dictated by role-specific requirements.

Health records documenting immunizations, tuberculosis screening and clearance, exposure investigations, medical evaluations, fit testing, and related health surveillance activities are maintained in accordance with institutional policies and applicable legal and regulatory standards. The Office of Institutional Health and Wellness is responsible for receiving, validating, and securely storing health records for students, employees, and volunteers as described below.

(1) Employees: Health records for School of Medicine (SOM) employees with direct patient care responsibilities are maintained by designated offices within each SOM department. Health records for employees outside the SOM engaged in direct patient care are managed centrally through the Office of Institutional Health and Wellness. All records are kept confidential and accessible only to authorized personnel.

(2) Students: The Office of Institutional Health and Wellness receives, validates, and maintains recommended pre-matriculation immunization documentation. Annual tuberculosis testing, influenza vaccination documentation, and exposure management records are also coordinated and stored by this office to ensure compliance and facilitate clearance for clinical activities.

(3) Volunteers: Each ÍâÍøÌìÌà campus with an active volunteer program designates an office responsible for maintaining health surveillance records of volunteers. These offices coordinate with the Office of Institutional Health and Wellness to ensure compliance with health clearance recommendations.

All health records are retained for the duration required by state and federal regulations, institutional policy, and in alignment with guidelines from agencies such as OSHA and CDC. Specific retention periods and procedures are detailed in institutional records management policies. Individuals’ health information is protected under applicable privacy laws, including HIPAA, and is not disclosed without proper authorization except as required by law.

For detailed procedures, timelines for submission, forms, and contact information regarding health clearance and records retention, please refer to the ÍâÍøÌìÌà Institutional Health and Wellness website.

5. Program Costs: 

a. ÍâÍøÌìÌà covers the costs associated with health surveillance services that fall within the standard operating recommendations of the Health Surveillance Program. However, if an individual is required to undergo additional clinical evaluations, diagnostics, or interventions beyond the routine scope of the program, whether due to specific job duties, regulatory or clinical site requirements, or personal health circumstances, those additional costs are the responsibility of the individual.

b. Individuals may contact the Office of Institutional Health and Wellness to obtain the current fee schedule and information about the process for accessing these services. In some cases, individuals may be able to submit costs to their personal health insurance for coverage; it is the responsibility of the individual to confirm insurance eligibility and reimbursement.

6. Responsibilities:

a. Office of Institutional Health and Wellness: Responsible for administering the Health Surveillance Program, including oversight of health clearance, recordkeeping, compliance monitoring, and coordination with campus health surveillance units to ensure program effectiveness.

b. Covered Individuals: Responsible for reporting any exposure incidents to their immediate supervisor, or as otherwise designated per campus protocol, and for obtaining all immunizations/tests as recommended under the program.

c. Deans or Dean’s Designee of each School:

(1) Responsible for designating the school’s Institutional Health Resource office, entity, or individual and communicating with the Office of Institutional Health and Wellness to ensure that the program operates in accordance with this policy.

(2) Require personnel under their supervision to attend scheduled training sessions and keep follow-up appointments as necessary with the Office of Institutional Health.

(3) Responsible for implementing disciplinary action, if necessary, in matters of non-compliance involving covered individuals under their supervision.

d. Supervisors and Department Managers: Responsible for ensuring that employees and trainees in their units comply with health surveillance recommendations, report exposures promptly, and participate in recommended training and evaluations.

e. Director of Volunteer Services: Responsible for informing all volunteers regarding the Office of Institutional Health and Wellness and ensuring compliance.

f. Laboratory Animal Resources Centers (LARC): Responsible for implementing and coordinating the Animal Occupational Health Program within their facilities, ensuring that personnel working with animals receive appropriate health surveillance, training, and clearance.

7. Compliance with the Health Surveillance Program: Compliance with the ÍâÍøÌìÌà Health Surveillance Program is recommended for all covered individuals as a condition of participation in clinical, research, educational, and occupational activities. Adherence to recommended immunizations, screenings, training, and reporting protocols is essential to maintain a safe and healthy environment for patients, personnel, and the community.

Failure to comply with program recommendations, including timely submission of health documentation, participation in recommended testing or training, and reporting of exposure incidents, may result in restrictions on access to clinical or research facilities, suspension of privileges, or other disciplinary actions as determined by the appropriate school or institutional authorities.

Supervisors, Deans, and designated institutional officials are responsible for enforcing compliance within their units and for ensuring that covered individuals receive appropriate guidance and support to meet program obligations.

The Office of Institutional Health and Wellness monitors compliance and assists individuals and departments in fulfilling program requirements. Detailed information on compliance expectations, deadlines, and reporting is available on the Institutional Health and Wellness website at /institutional-health.