Download the OSHA manual - Wisconsin Dental Association

EXPOSURE DETERMINATION FORMDental Office/Practice/Facility Name:Address:Dr. Doe Dental000 Apple StreetAny Town, USA 12345Dr. John Doe and Dr. John SmithEmployer Name(s):must acknowledge their responsibility to provide all employees who perform taskswhich could potentially place them at risk for occupational exposure to bloodand/or other potentially infectious materials with full protection as stated in theOSHA Bloodborne Pathogens Standard 29 CFR part 1910.1030.FORM1sThis exposure determination has been made without regard to the use of personal protective equipment.DentistsDental HygienistsLab Technicians/OtherReceptionistJOB CLASSIFICATIONList all job classifications in which employees haveoccupational exposure in this office/practice/facilityDental AssistantsDental Intern*List job classifications in which some, not all, employees,have occupational exposure in this office/practice/facilityTASKS AND PROCEDURES IN WHICH OCCUPATIONAL EXPOSURE WILL OCCUROperatory cleanup procedures including cleaningand processing instruments, disinfection of allcontaminated surfaces and replacement of paperand plastic drapes.These duties are performed byreceptionist when dental assistant is on vacation.SAMPLE* If this person is an unpaid student he/she is not covered by the OSH Act (OSHA). However, for liability purposes, it is wise to include them in your program.OSHA EXPOSURE CONTROL PLAN…a member benefit from the WDA 5