Aerosol Transmissible Disease Exposure Control Plan

Purpose & Authority

The purpose of this plan is to outline the procedures needed to minimize the risk of illness from aerosol transmissible diseases. The Aerosol Transmissible Disease (ATD) Exposure Control Plan is intended to comply with Title 8 California Code of Regulations (CCR) §5199.  As of October 5, 2020, this plan has also been developed to include some guiding principles from the United  States Centers for Disease Control (CDC) “Considerations for Institutions of Higher Education” (IHE’s). It is recommended to check the CDC website periodically for updated interim guidance since updates will be made as additional information becomes available.  Please refer to CSUDH’s “Campus COVID-19 Response & Safety Plan” for more information on campus specific guidelines associated with COVID-19.

This plan delineates effective written infection control procedures to control the risk of transmission of aerosol transmissible diseases as required at CSUDH. Oversight of the overall CSUDH campus ATD plan will be managed though the office of Environmental Health and Safety (EH&S).  Components of this plan that apply to the CSUDH Student Health Center (SHC) will be overseen by the Charge Nurse of the SHC. The charge nurse is responsible for administering, implementing, maintaining and updating sections of this plan that pertain to the SHC. Her backup is CSUDH Chief of Medical Services. Sections of this plan that pertain to other CSUDH campus constituents are overseen by the EH&S manager/administrator.  

This plan outlines screening procedures for ATD.  Screening procedures performed in the medical setting will be described below. When screening is provided by persons who are not health care providers, refer to Title 8 CCR 5199 Appendix (F) for sample criteria for screening in non-medical settings.

The infection control procedures include procedures for the cleaning and disinfection of work areas, vehicles, and equipment that may become contaminated with ATPs and pose an  infection risk to employees. These written procedures will be available at the worksites.


According to Title 8 CCR §5199 the following facilities, service categories, or operations at CSUDH are covered under this plan:

  • Student Health Center (SHC)
  • Police services provided during transport or detention of persons reasonably anticipated to be cases or suspected cases of aerosol transmissible diseases; and police services provided in conjunction with health care or public health operations
  • Maintenance, renovations, service, or repair operations involving air handling systems or equipment or building areas that may reasonably be anticipated to be contaminated with aerosol transmissible pathogens (ATPs), including:
    • Areas in which Airborne Infectious Disease (AirID) cases and suspected cases are treated or housed.
    • Air handling systems that serve airborne infection isolation rooms or areas (AIIRs).
    • Equipment such as laboratory hoods, biosafety cabinets, and ventilation systems that are used to contain infectious aerosols.

The following job classifications may have occupational exposure to ATDs at CSUDH:

  • SHC staff exposed to ATDs due to their work activities including:
    • Medical Doctors (MDs)
    • Nurse Practitioners (NPs)
    • Registered Nurses (RNs)
    • Licensed Vocational Nurses (LVNs)
  • Custodial employees who clean airborne infection isolation (AII) rooms or areas
  • Building Service Engineers (BSE) who maintain, renovate, service, or repair the air handling system, equipment, or building areas in the SHC
  • University Police Officers who conduct field operations in which occupational exposure is possible and who refer AirID cases and suspected cases to other facilities

By definition, CSUDH is classified as a “Referring Employer” and is therefore only required to comply with provisions of Title 8 CCR §5199 subsection (a), subsection (c), including all parts of Section 5199 referred to in subsection (c), and subsection (j) of the standard.


Aerosol transmissible disease (ATD) or aerosol transmissible pathogen (ATP) - A disease or pathogen for which droplet or airborne precautions are required, as listed in Appendix A.


Airborne infection isolation (AII) - Infection control procedures as described in Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings.  These procedures are designed to reduce the risk of transmission of airborne infectious pathogens, and apply to patients known or suspected to be infected with epidemiologically important pathogens that can be transmitted by the airborne route.


Airborne infection isolation room or area (AIIR) - A room, area, booth, tent, or other enclosure that is maintained at negative pressure to adjacent areas in order to control the spread of aerosolized M. tuberculosis and other airborne infectious pathogens and that meets the requirements stated in subsection (e)(5)(D) of this standard.


Airborne infectious disease (AirID) - Either: (1) an aerosol transmissible disease transmitted through dissemination of airborne droplet nuclei, small particle aerosols, or dust particles containing the disease agent for which AII is recommended by the CDC or CDPH, as listed in Appendix A, or (2) the disease process caused by a novel or unknown pathogen for which there is no evidence to rule out with reasonable certainty the possibility that the pathogen is transmissible through dissemination of airborne droplet nuclei, small particle aerosols, or dust particles containing the novel or unknown pathogen.


Airborne infectious pathogen (AirIP) - Either: (1) an aerosol transmissible pathogen transmitted through dissemination of airborne droplet nuclei, small particle aerosols, or dust particles containing the infectious agent, and for which the CDC or CDPH recommends AII, as listed in Appendix A, or (2) a novel or unknown pathogen for which there is no evidence to rule out with reasonable certainty the possibility that it is transmissible through dissemination of airborne droplet nuclei, small particle aerosols, or dust particles containing the novel or unknown pathogen.


CDC - United States Centers for Disease Control and Prevention.


CDPH - California Department of Public Health and its predecessor, the California Department of Health Services (CDHS).


Case - Either of the following:  (1) A person who has been diagnosed by a health care provider who is lawfully authorized to diagnose, using clinical judgment or laboratory evidence, to have a particular disease or condition. (2) A person who is considered a case of a disease or condition that satisfies the most recent communicable disease surveillance case definitions established by the CDC and published in the Morbidity and Mortality Weekly Report (MMWR) or its supplements.


Droplet precautions - Infection control procedures as described in Guideline for Isolation Precautions are designed to reduce the risk of transmission of infectious agents through contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (larger than 5 mm in size) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism.


Exposure incident - An event in which all of the following have occurred: (1) An employee has been exposed to an individual who is a case or suspected case of a reportable ATD, or to a work area or to equipment that is reasonably expected to contain ATPs associated with a reportable ATD; and (2) The exposure occurred without the benefit of applicable exposure controls required by this section, and (3) It reasonably appears from the circumstances of the exposure that transmission of disease is sufficiently likely to require medical evaluation.


Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings - The Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, December 2005, CDC, which is hereby incorporated by reference for the sole purpose of establishing requirements for airborne infection isolation.


High hazard procedures - Procedures performed on a person who is a case or suspected case of an aerosol transmissible disease in which the potential for being exposed to aerosol transmissible pathogens is increased due to the reasonably anticipated generation of aerosolized pathogens. Such procedures include, but are not limited to, sputum induction, bronchoscopy, aerosolized administration of pentamidine or other medications, and pulmonary function testing.  High Hazard Procedures also include, but are not limited to, autopsy, clinical, surgical and laboratory procedures that may aerosolize pathogens.


High risk settings The more a person interacts with others, and the longer that interaction lasts, the higher the risk of ATP spread in the community. Risk is also affected by factors such as background rates of infection in the community and individuals’ compliance with mitigation strategies, such as use of masking, social distancing, and hand hygiene. CSUDH will communicate their selected level of risk so that people can make more informed decisions about attendance, especially those with disabilities and people who are at higher risk of severe illness from COVID. The risk of COVID-19 spread increases in IHE non-residential (i.e., off-campus housing) and residential (i.e., on-campus housing) settings with the level of COVID activity in the community.


Laboratory. A facility or operation in a facility where the manipulation of specimens or microorganisms is performed for the purpose of diagnosing disease or identifying disease agents, conducting research or experimentation on microorganisms, replicating microorganisms for distribution or related support activities for these processes.


Occupational exposure - Exposure from work activity or working conditions that is reasonably anticipated to create an elevated risk of contracting any disease caused by ATPs if protective measures are not in place. In this context, “elevated” means higher than what is considered ordinary for employees having direct contact with the general public. Whether a particular employee has occupational exposure depends on the tasks, activities, and environment of the employee, and therefore, some employees of a covered employer may have no occupational exposure. For example, occupational exposure typically does not exist where a hospital employee works only in an office environment separated from patient care facilities, or works only in other areas separate from those where the risk of ATD transmission, whether from patients or contaminated items, would be elevated without protective measures.


Referring employer - Any employer that operates a facility, service, or operation in which there is occupational exposure, and which refers AirID cases and suspected cases to other facilities. Referring facilities, services and operations do not provide diagnosis, treatment, transport, housing, isolation or management to persons requiring AII. General acute care hospitals are not referring employers. Law enforcement, corrections, public health, and other operations that provide only non- medical transport for referred cases are considered referring employers if they do not provide diagnosis, treatment, housing, isolation or management of referred cases.


Respirator - A device which has met the requirements of 42 CFR Part 84, has been designed to protect the wearer from inhalation of harmful atmospheres, and has been approved by NIOSH. for the purpose for which it is used.


Respirator user - An employee who in the scope of their current job may be assigned to tasks which may require the use of a respirator, in accordance with subsection (g).

Respiratory Hygiene/Cough Etiquette in Health Care Settings. Respiratory Hygiene/Cough Etiquette in Health Care Settings, CDC, November 4, 2004, which is hereby incorporated by reference for the sole purpose of establishing requirements for source control procedures.


Source control measures - The use of procedures, engineering controls, and other devices or materials to minimize the spread of airborne particles and droplets from an individual who has or exhibits signs or symptoms of having an ATD, such as persistent coughing.

High Hazard Procedures & High Risk Settings

No high hazard procedures, as defined above, are performed at CSUDH.

Tasks Requiring Respiratory Protection

SHC personnel and other identified job classifications at CSUDH departments with occupational risk for AirID will be provided with personal protective equipment by CSUDH that is appropriate to their jobs.  SHC clinical staff are provided with eye protection, disposable gowns, and non-latex single-use gloves.  Other job classifications with occupational exposure risk for AirID will be provided with non-latex gloves and other Personal Protective Equipment as needed.  All job classifications identified to require access to the use of an N-95 respirator will be medically assessed, trained, and fit tested with the appropriate N-95 single use filtering face piece respirator per Title 8 CCR §5144.


The following job assignments or tasks may require respiratory protection:

  • SHC clinical staff such as MDs, NPs, RNs, and LVNs who may come within six feet of AirID cases
  • Physical or Central Plant Staff assigned to clean or maintain the SHC isolation room, RM C-108

University Police Officers assigned to transport potential AirID cases from class, other academic areas, common university areas, or student housing.  University Police officers may also be required to transport from off campus locations as well.

Exposure Control Measures

SHC custodial staff that may encounter ATPs will be provided appropriate training to include proper cleaning and disinfection of building components including the isolation room (if one is available).  University Police who transport suspected or confirmed AirID cases will be provided with instructions on how to clean and disinfect their vehicles.


Specific control measures for CSUDH are identified below:

  • Engineering controls include regular service intervals of building air handling and distribution systems in the SHC to ensure optimum performance of the building HVAC system.
  • Work practice controls include regular in-service training for staff on the importance of proper hand washing practice, along with adoption of regulatory guidelines relative to the control of infectious disease in health care settings.
  • Recommend and reinforce handwashing with soap and water for at least 20 seconds. If soap and water are not readily available, hand sanitizer that contains at least 60% alcohol can be used. Methanol Based hand sanitizers shall not be used.  To reinforce the hand wash behavior, independent hand sanitization stations are located throughout the Student Health Services building (e.g. touchless hand sanitizer stations placed by building doorways; handwashing stations positioned near high touch areas), along with instructions on use, and motivational literature designed to encourage hand sanitization etiquette.
  • Encourage students, faculty, and staff to cover coughs and sneezes with a tissue or use the inside of the elbow. Used tissues should be thrown in the trash and hands washed immediately with soap and water for at least 20 seconds.


Hand Hygiene and Respiratory Etiquette

  • Students, faculty, and staff are encouraged to cover coughs and sneezes with a tissue or use the inside of the elbow. Used tissues should be thrown in the trash and hands washed immediately with soap and water for at least 20 seconds.  If soap and water are not readily available, hand sanitizer that contains at least 60% alcohol can be used.
  • CSUDH will ensure availability and access to supplies that promote healthy hygiene practices where appropriate (e.g., touchless hand sanitizer stations by building doorways; handwashing stations positioned near high touch areas).
Source Control Measures

Source control measures to be utilized in work areas where persons with suspected AirID symptoms are encountered:

  • Persons with suspected AirID symptoms will be provided with disposable tissues, hand hygiene materials, and masked with a surgical or procedural mask, or placed in such a manner that contact with employees not wearing respiratory protection is eliminated or minimized until transfer or placement in an AII can be accomplished, or
  • Persons with suspected AirID symptoms will be placed in an AII room or area or transferred to a facility with AII rooms or areas. The AII room will contain provisions for separate ventilation or filtration.  In most cases, CSUDH must ensure that transfer is performed within 5 hours of the identification of the case or suspected case.  Respiratory protection will be utilized by the campus Police during transport.
  • All employees entering the AII room or area housing individuals with suspected AirID are provided with and use appropriate personal protective equipment including a N-95 respirator.
  • At the SHC, individuals that require respiratory isolation, will be placed in room C-108, which has Negative Pressure ventilation. In such cases, SHC will keep the number of employees entering the isolation room to a minimum required to treat the patient.  Such employees will be properly protected with PPE, including N-95 masks as applicable and in accordance with 8CCR Section 5144 subsection (g), Respiratory Protection.
  • Where it is not feasible to provide AII rooms or areas to individuals suspected or confirmed to be infected with or carriers of novel or unknown ATPs, CSUDH shall provide other effective control measures to reduce the risk of transmission to employees, which shall include the use of respiratory protection in accordance with Title 8 CCR 5199 subsection (g) and Section 5144, Respiratory Protection.

If the isolation room is not available or there are more individuals requiring isolation than reasonable to isolate in C-106, such individuals may be temporarily asked to wait, masked, outside the back of the SHC, until transport to a receiving facility can be arranged.

Patient Referral
Employee Isolation & Transporting Procedures

CSUDH will use the following procedures regarding isolation of employees who report AirID symptoms:

  • Employees who suspect they are symptomatic of FLI or AirID are encouraged to stay home and seek treatment from their normal healthcare providers. Employees who have FLI symptoms should self-isolate from other family members, practice good hand hygiene, use source control methods (surgical masks) when around other family members, and remain away from work or public gatherings until 48 hours after fever and symptoms have abated.
  • A person requiring referral will be placed in a separate room or area with separate ventilation or filtration.
  • If employees plan to enter the room or area in which the person requiring referral is located (if that person is not compliant with source control measures) then a respirator will be used in accordance with Title 8, Section 5144, Subsection (g), Respiratory Protection.
  • Campus police who transport a person requiring referral must wear a respirator unless all of the below conditions are met:
    • A solid partition separates the passenger area from the area where employees are located;
    • If written procedures have been implemented that specify the conditions of operation, including the operation of windows and fans;
    • If tests (e.g., by the use of smoke tubes) assess the airflow in a representative vehicle (of the same model, year of manufacture, and partition design) under the specified conditions of operation, and finds that there is no detectable airflow from the passenger compartment to the employee area;
    • If results of the tests are recorded and maintained in accordance with Title 8, 5199, subsection (j)(3)(F); and
    • The person performing the test is knowledgeable about the assessment of ventilation systems.
  • Immediately separate faculty, staff, and students with ATD symptoms(such as fever, cough, or shortness of breath). Individuals who are sick should go home or to a healthcare facility, depending on how severe their symptoms are, and follow CDC Guidance for caring for oneself and others who are sick. CSUDH may follow CDC’s Guidance for Shared or Congregate Housing for those that live in campus housing.
  • Campus administrators should immediately provide options to separate people with ATD symptoms by providing distance learning options, self-isolation rooms in dormitories or other housing facilities, and food delivery service for on-campus students in self-isolation.
  • Employees who report to work, and later develop AirID symptoms will be encouraged by their supervisors or appropriate administrators to take sick leave and remain away from work until fever and symptoms have abated.


The SHC treats only normally matriculated students, and as such does not treat employees, (except in cases of urgent or emergent situations, for the purpose of stabilization prior to referral out or transport).  Isolation procedures established by the SHC for students who present with AirID symptoms are described above, see Source Control Measures. After initial contact with the clinician, if it is determined that it is appropriate for the student to isolate at home, the following apply:

  • If patient does not reside on campus housing, patient will be advised to go home and self-isolate until no longer symptomatic.

If patient is housed on campus, the SHC will contact Student Housing and advise that a resident is symptomatic for AirID.  The patient/student will be housed in a single room, equipped with a dedicated ventilation and heating system until no longer symptomatic.

Employee Medical Services

Employee medical services are provided by CSUDH through a contracted occupational medical provider, Concentra. Required vaccinations are offered to clinicians and employees with potential occupational exposure including MDs, NPs, RNs, LVNs, University Police Officers, and select employees that may perform cleaning or maintenance at the SHC, including the isolation room.  An employee who is offered required vaccinations, but declines, is required to sign a declination of vaccination form, which becomes a part of the employee’s permanent medical record.  If a required vaccine is requested by CSUDH from the contracted medical provider, and there is a delay in vaccine delivery, the contracted medical provider will provide a written declaration to CSUDH that the vaccine is unavailable and provide an estimate of when the vaccine will be available.


CSUDH will also offer vaccinations against seasonal influenza to all employees with occupational exposure, during the period designated by the CDC for administration.

Exposure Incident Procedures

If CSUDH is informed that an employee may have a reportable aerosol transmissible disease (RATD) or has been exposed to someone who may have a RATD, the following actions shall be taken:

  • Within 72 hours of the time CSUDH was informed regarding the potential occupationally related exposure, the pertinent facts surrounding the exposure will be gathered by the appropriate administrator to determine if a significant exposure may have occurred (significant exposure means working within six feet of a suspected AirID person, or being directly exposed to aerosol droplets from a person with suspected AirID). This report and subsequent required reporting and decision making shall be conducted by a campus employee with demonstrated knowledge of epidemiology and the methods for controlling infectious disease exposure.  If a determination is made that a significant exposure to a CSUDH employee has not occurred, and that no post-exposure prophylaxis is required, the information used to make that determination shall be documented.
  • Within 96 hours of the significant exposure, CSUDH shall notify employees in adjacent work stations regarding the nature of the potential exposure.

As soon as feasible, CSUDH shall provide post-exposure medical evaluations to employees who may have had a significant exposure to the index case. The medical evaluation shall be performed by the CSUDH occupational medical provider.

Exposure Incident Evaluation

CSUDH will assess each suspected exposure incident involving an employee according to established incident investigation protocols detailed in the CSUDH Injury and Illness Prevention Program.  Refer to that document for written procedures.

Communication to Employees of AirID Cases

CSUDH will maintain contact with the facility who received the referred patient to obtain necessary infection control information so that it can be provided to employees who were exposed to the referred patient.


Managers and supervisors shall maintain current public health information provided by CSUDH on AirID cases at CSUDH.  Employees that may have occupational exposure to AirID suspected or confirmed cases must be briefed on these cases. The briefings shall be recorded in writing and maintained as required by CSU Record Retention guidelines.

Communication to Public Health Authorities & Close Contacts

Cases or suspected cases of specific AirIDs must be reported to the local health officer per Title 17 CCR §2500.  The CSUDH ATD Program Administrator is responsible to ensure the reporting requirements to the local health officer are fulfilled, and will designate an employee with a medical background (i.e. SHC employee, Concentra employee) to do so, depending on the situation. All HIPAA (Health Insurance Portability and Accountability Act) guidelines regarding patient confidentiality will be observed as required.

Reporting requirements and details on which AirIDs must be reported is available at

Personal Protective Equipment (PPE)

The SHC, University Police, and any additionally identified campus departments or offices where occupational exposure to AirID may occur will procure and maintain adequate supplies of NIOSH-approved N-95 respirators in required sizes.  Methods for ensuring adequate supplies shall be developed by the identified departments based on the following general guideline.  


Departments will maintain a list of medically evaluated, fit tested, and trained employees that are approved by EHS to wear a respirator and are included in the CSUDH Respiratory Protection Program per Title 8 CCR §5144. Each department shall maintain a supply of N-95 respirators sufficient to supply one respirator per covered employee per shift, plus 5% for additional incidental use.


In addition, SHC clinical staff will be provided with eye protection, disposable gowns, and non-latex single-use gloves Other job classifications with occupational exposure risk for AirID will be provided with non-latex gloves.

Employee Training

All employees with occupational exposure to ATPs must be trained on this plan.  All personnel must be informed of the hazards associated with the work performed and proper safety precautions.  ATD training is required at the time of initial assignment to tasks where occupational exposure may occur and at least annually thereafter.  In addition, training is required when changes occur in procedures that could affect worker exposure to ATPs, such as the introduction of new engineering or work practice controls or modification of tasks and procedures.


This training includes:

  • A general explanation of ATDs including the signs and symptoms that require further medical evaluation;
  • Screening methods and criteria for persons who require referral;
  • CSUDH’s source control measures and how these measures will be communicated to persons the employees contact;
  • CSUDH’s procedures for making referrals;
  • Procedures for temporary risk reduction measures prior to transfer;
  • Training when respiratory protection is used;
  • CSUDH’s medical services procedures, the methods of reporting exposure incidents, and procedures for providing employees with post-exposure evaluation;
  • Information on vaccines that will be made available, including the seasonal influenza vaccine. For each vaccine, this information will include the efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge;
  • How employees can access CSUDH’s written procedures and how employees can participate in reviewing the effectiveness of the procedures; and
  • An opportunity for interactive questions and answers with a person who is knowledgeable in the subject matter as it relates to the workplace that the training addresses and who is also knowledgeable in CSUDH’s infection control procedures. Training not given in person will provide for interactive questions to be answered within 24 hours by a knowledgeable person.


Infection control procedures are reviewed at least annually by the administrator and by employees regarding the effectiveness of the program in their respective work areas, and deficiencies found will be corrected.


CSUDH will maintain training records, vaccination records, records of exposure incidents, and records of inspection, testing, and maintenance of non-disposable engineering controls.  Where respirators are used, CSUDH will maintain records of implementation of the Respiratory Protection Program in accordance with Title 8, Section 5144, Respiratory Protection.

Medical Records

Medical records generated by employees treated for occupationally acquired illnesses will be maintained as required and stipulated in the Employee Medical Monitoring Plan and by the CSU System Executive Order 1031.  HIPPA provisions govern the maintenance and access to employee medical records.


Training records shall be maintained for 3 years from the date on which the training occurred and include the following information:

  • The date(s) of the training session(s);
  • The contents or a summary of the training session(s);
  • The names and qualifications of persons conducting the training or who are designated to respond to interactive questions; and
  • The names and job titles of all persons attending the training sessions.


Annual Review

Records of annual review of the ATD Plan and Biosafety Plan shall include the name(s) of the person conducting the review, the dates the review was conducted and completed, the name(s) and work area(s) of employees involved, and a summary of the conclusions. The record shall be retained for three years.


Records of exposure incidents shall be retained and made available as employee exposure records in accordance with Title 8, Section 3204. These records shall include:

  • The date of the exposure incident;
  • The names, and any other employee identifiers used in the workplace, of employees who were included in the exposure evaluation;
  • The disease or pathogen to which employees may have been exposed;
  • The name and job title of the person performing the evaluation;
  • The identity of any local health officer and/or Physician or Other Licensed Health Care Professional (PLHCP) consulted;
  • The date of the evaluation; and
  • The date of contact and contact information for any other employee who either notified the employer or was notified by the employer regarding potential employee exposure.


Records of the unavailability of a vaccine shall include the name of the person who determined that the vaccine was not available, the name and affiliation of the person providing the vaccine availability information, and the date of the contact. This record shall be retained for three years.


Records of the unavailability of AII rooms or areas shall include the name of the person who determined that an AII room or area was not available, the names and the affiliation of persons contacted for transfer possibilities, and the date of the contact, the name and contact information for the local health officer providing assistance, and the times and dates of these contacts. This record, which shall not contain a patient's individually identifiable medical information, shall be retained for three years.


CSUDH does not perform in-patient medical care for patients with ATD’s and therefore there is no requirement to keep records of decisions not to transfer patients to another facility. All patients requiring transfer will be sent for a higher level care.


Records of inspection, testing and maintenance of non-disposable engineering controls including ventilation and other air handling systems, air filtration systems, containment equipment, biological safety cabinets, and waste treatment systems shall be maintained for a minimum of five years and shall include the name(s) and affiliation(s) of the person(s) performing the test, inspection or maintenance, the date, and any significant findings and actions that were taken.


Records of the respiratory protection program shall be established and maintained in accordance with Title 8, Section 5144, Respiratory Protection.  Employers who provide fit-test screening, in accordance with the exception to subsection (g)(6)(B)3 shall retain the screening record for two years.



CSUDH shall ensure that all records required to be maintained shall be made available upon request to the Cal/OSHA and NIOSH and the local health officer for examination and copying.


Employee training records, the exposure control plan and/or biosafety plan, and records of implementation of the ATD exposure control plan and biosafety plan, other than medical records containing individually identifiable medical information, shall be made available as employee exposure records in accordance with Title 8, Section 3204(e)(1) to employees and employee representatives.


Employee medical records required shall be provided upon request to the subject employee, anyone having the written consent of the subject employee, the local health officer, and to the Chief and NIOSH in accordance with Section 3204 of these orders, Access to Employee Exposure and Medical Records, for examination and copying.


Transfer of Records

CSUDH will comply with the requirements involving the transfer of employee medical and exposure records that are set forth in Title 8, Section 3204, Access to Employee Exposure and Medical Records, of these orders.


If CSUDH ceases to do business and there is no successor employer to receive and retain the records for the prescribed period, CSUDH shall notify the Cal/OSHA and NIOSH, at least three months prior to the disposal of the records and shall transmit them to NIOSH, if required by NIOSH to do so, within that three-month period.

Plan Review & Employee Involvement

This plan will be annually reviewed for effectiveness by the Program Administrator and/or whenever processes change. The CSUDH campus Health & Safety committee meets at least quarterly and will review these procedures as needed.  Employees or their representatives interested in improving the procedures contained in this plan may participate in these committee meetings by contacting the Program Administrator.

Surge Procedures

CSUDH will not provide surge capacity services (rapid deployment of experienced coordination experts).  Surge procedures on campus will be guided by Los Angeles County Public Health and the CSU Chancellor’s Office.