Environment, Health and Safety Manual – Chapter 06.06: Clinical Safety – Policy on Immunization for UNC-Chapel Hill Employees Credentialed by UNC Health or Otherwise Performing Job Duties in Patient-Facing Settings within UNC Health or the UNC-Chapel Hill School of Medicine

Environment, Health & Safety

Title

Environment, Health and Safety Manual – Chapter 06.06: Clinical Safety – Policy on Immunization for UNC-Chapel Hill Employees Credentialed by UNC Health or Otherwise Performing Job Duties in Patient-Facing Settings within UNC Health or the UNC-Chapel Hill School of Medicine

Purpose

Support the UNC Health and University of North Carolina at Chapel Hill (UNC-Chapel Hill) School of Medicine (SOM) strategy for providing a safer environment for health care personnel and patients through influenza and COVID-19 vaccination, while also meeting applicable regulatory requirements.

Rationale

To protect patients, employees, employees’ family members, and the community from infection through (1) annual influenza vaccination; and (2) a primary series of the COVID-19 vaccination of UNC-Chapel Hill faculty and staff who are credentialed by UNC Hospital (e.g., Physicians, Nurses, Physician Assistants, etc.) or who otherwise perform job duties in patient-facing settings within UNC Health or UNC-Chapel Hill SOM facilities, clinics, or programs (e.g., front desk staff).

Applicability

This Policy applies to UNC-Chapel Hill SHRA and EHRA (Faculty and Non-Faculty) employees who are credentialed by UNC Health or who otherwise perform job duties in patient-facing settings within UNC Health or UNC-Chapel Hill SOM community-based clinics, centers, institutes, and programs enrolled in Medicare/Medicaid-certified provider and supplier types.

Policy

Annual Influenza Immunization

All clinical medical faculty and staff employed by UNC-Chapel Hill and credentialed by UNC Health to provide direct patient care or who otherwise perform job duties in a patient-facing setting within UNC Health or UNC-Chapel Hill SOM community-based clinics, centers, institutes, and programs enrolled in Medicare/Medicaid-certified provider and supplier types, must be immunized against influenza each year. Influenza vaccine is available free of charge to all UNC-Chapel Hill employees. The vaccination program is coordinated through the UNC-Chapel Hill Employee Occupational Health Clinic (UEOHC) and UNC Health Occupational Health group beginning September 1 (pending availability of the vaccine). Immunizations must be completed by January 15 unless on leave (e.g., sick leave, pregnancy, Workers Compensation). If returning from leave that includes January 15, employees will have one (1) month to become compliant.

Employees who are vaccinated through services other than UNC Health Occupational Health (e.g. private physician office, public clinics) must provide proof of immunization to the UEOHC. Proof of flu immunization may include a physician’s or pharmacist’s note or a receipt.

COVID-19 Vaccination

All clinical medical faculty and staff employed by UNC-Chapel Hill and credentialed by UNC Health to provide direct patient care or who otherwise perform job duties in a patient-facing setting within UNC Health or UNC-Chapel Hill SOM community-based clinics, centers, institutes, and programs enrolled in Medicare/Medicaid-certified provider and supplier types, must receive all doses of a primary series of a COVID-19 vaccine authorized or approved in the United States, including: Pfizer-BioNtech (2 doses); OR Moderna (two doses of vaccine); OR Johnson and Johnson’s Janssen (one dose of vaccine); OR Novavax (two doses).

Employees must provide (1) certification; and (2) proof of vaccination to UNC-Chapel Hill Department of Environment, Health & Safety (EHS) “COVID-19 Vaccine Certification” webpage.

Proof of vaccination will require the employee to upload one of the following:

  1. the employee’s COVID-19 Vaccination Record Card;
  2. a copy of medical records documenting the vaccination;
  3. a copy of immunization records from a public or state immunization information system; or
  4. a copy of any other official documentation containing required data points (the required data points for such other official documentation are the type of vaccine administered, date(s) of administration, and the name of the health care professional(s) or clinic site(s) administering the vaccine(s).

Accommodations/Exemptions

  • Medical and religious accommodations to immunization required by this Policy may be granted for employees who qualify. Employees claiming religious exemption must submit a request on the EHS “Medical Contraindication Declination Certification Application” webpage.
  • Employees requesting exemption due to medical contraindications must submit a request on the EHS “Religious Declination Certification Application” webpage and may be required to provide proof of medical contraindications, such as a letter and medical records from their private physician.
  • Exemptions for personal, non-religious beliefs will not be accepted. Standard criteria for medical exemption will be established based upon recommendations from the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP).
  • Each request for exemption, regardless of the reason, will be evaluated individually by UNC-Chapel Hill. If an exemption is granted, the employee will be notified promptly in writing.
  • For further information about exemptions, please see UNC-Chapel Hill’s Equal Opportunity and Compliance website.

Maintaining Immunization Records

EHS will maintain a record of influenza and COVID-19 vaccination as well as a list of employees with accommodations.

Dates of Flu Immunization

Flu vaccinations will begin September 1 (pending availability of the vaccine). “Designated” UNC-Chapel Hill employees must be vaccinated annually or granted an exemption prior to January 15.

Influenza Vaccine Shortage

In the event of an influenza vaccine shortage, the situation will be evaluated at the UNC Health level for the entire organization. Influenza vaccine will be offered to credentialed UNC-Chapel Hill employees and UNC-Chapel Hill employees operating in a patient-facing role based on job function and risk of exposure to influenza. Priority will be given to those who provide direct hands-on patient care with prolonged face-to-face contact with patients and/or have highest risk of exposure to patients with influenza and as recommended/required by CDC, ACIP, US Food and Drug Administration (FDA), Society for Healthcare Epidemiology of America (SHEA), and the NC Department of Health and Human Services.

Compliance

It is the responsibility of designated employees to comply with this Policy. It is the responsibility of the Supervisor/Department Head/Division Director to ensure all employees in their area(s) of responsibility are aware of this Policy. Failure to timely comply with the requirements of this Policy, including completion of the required vaccination schedule or otherwise obtaining a religious or medical exemption, may lead to disciplinary action up to and including termination. See Chapter 01.11: EHS Management System – Enforcement of Training and Medical Surveillance.

Additionally, on an annual basis, EHS will provide the appropriate UNC-Chapel Hill and UNC Health administrators a list of personnel who are non-compliant with the flu vaccination requirements of this Policy on January 15. Employees who are non-compliant with the flu vaccination requirements as of January 15 may have their UNC Health privileges and/or UNC-Chapel Hill SOM clinical care duties suspended until either they become compliant or until the end of the influenza season (usually around May 30) for the flu vaccine requirement. UNC Health administrators will determine the date after which employees who have not received their vaccination in accordance with this Policy may resume their privileges and/or clinical care duties. This deadline may be extended at the discretion of the UNC-Chapel Hill UEOHC Director and Director of EHS at the request of the UNC Health Chief Operating Officer or their designee.

**PLEASE NOTE: UNC-Chapel Hill students, faculty, and staff that work, volunteer, or are trainees participating in clinical rotations or patient-facing job responsibilities with outside health care providers or facilities, may be required to comply with applicable facility policies, including immunization policies. Consult your facility supervisor, sponsor, program director and/or trainer, as applicable, to request information about the facility’s immunization policy requirements.

Contact Information

Policy Contact

Environment, Health and Safety
1120 Estes Drive
Campus Box #1650
Chapel Hill, NC 27599-1650
Phone: 919-962-5507

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