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DHHS POLICIES AND PROCEDURES

_______________________________________________________________________________________________________________

Section V:

Human Resources

Title:

Safety and Benefits

Chapter:

Recordkeeping Policy

Current Effective Date:

9/1/05

Revision History:

 

Original Effective Date:

6/1/93

_______________________________________________________________________________________________________________

Purpose

To specify the types of records which shall be maintained by the Department of Health and Human Services (DHHS) Safety and Health Program, and access to records by other employees, and the retention schedules for each.

Policy

  1. Each division/facility/school shall maintain the following safety and health records for the time periods specified and shall provide such records without cost to any affected employee or his/her designated representative within the specified timeframe.
    1. Log and Summary of Occupational Injuries and Illnesses:
      1. The division/facility/school safety and health director/workers’ compensation representative shall maintain up-to-date logs of occupational illnesses and injuries.
      2. The division/facility/school safety and health director/workers’ compensation representative shall create an annual summary of occupational injuries and illnesses by January 20th of each following year. The summary shall be posted in prominent locations available to all affected employees from February 1st to April 30th of each year.
      3. Each log and summary shall be retained by the division/facility/school for no less than five (5) years following the year of record.
      4. Any employee or designated representative shall be provided a copy of any log and/or summary on file within 24 hours of notification to the division/facility/school safety and health director.
    2. Each division/facility/school safety and health director/workers’ compensation representative shall prepare a quarterly statistical report of all occupational injuries and illnesses and shall submit it to the DHHS-DHR, Safety and Benefits Office:
      1. The report shall identify all occupational injuries and illnesses for the quarter and cumulatively for the year, and shall be sorted by Nature of Injury, Type of Accident, Part of Body Affected, and Type of Medical Treatment.
      2. These reports shall be maintained by the division/facility/school safety and health director/workers’ compensation representative for one (1) year following the year of record.
      3. These reports shall be made available to any employee within 24 hours of request to the division/facility/school safety and health director/workers’ compensation representative.
    3. Workers’ Compensation Records:
      1. The Employee's Report of Adverse Event, the Supervisor's Accident Investigation Report, the Industrial Commission Form 19, and any Serious Injury Report shall serve as the supplemental record of any injury or illness reported by employees, and shall be maintained by the division/facility/school safety and health director/workers’ compensation representative for no less than five (5) years following the year of the injury or illness.
      2. A copy of the above documentation and all other documentation relating to each Workers’ Compensation recordable and medical only claim shall be maintained by the Third Party Administrator for no less than seven (7) years following the date of separation of the injured employee from department service.
      3. An employee or designated representative shall be provided a copy of any workers' compensation records pertaining to that employee within one (1) week of written request to the division/facility/school safety and health director/workers’ compensation representative.
    4. Training Records and Certifications:
      1. The DHHS Safety Program Manager shall retain the lesson plan and supplemental training materials for each department-level safety training course for the duration of use and for one (1) year following cancellation or replacement. Each division/facility/school and committee shall retain the lesson plans and supplemental training materials for courses it creates for the same time period.
      2. Each division/facility/school shall retain the certifications of employee training required in DHHS Safety and Benefits Recordkeeping Policy for at least one (1) year following successful completion of training or until replaced by an updated certification, whichever is shorter.
      3. An employee shall be provided with a copy of any training certification within one (1) hour of verbal request.
    5. Employee Exposure Records:
      1. All exposure records generated by the Safety and Health Program shall be retained by the affected division/facility/school for 30 years following the year of generation.
      2. Exposure records shall be made available to any authorized employee, former employee, or designated representative within 15 days of written request to the division/facility/school safety and health director/workers’ compensation representative.
      3. Confined Space Entry Permits which are canceled due to failure of entry conditions relating to atmosphere or hazardous substance exposure shall be classified as exposure records and retained under these policies.
    6. Medical Records:
      1. A complete file on each workers’ compensation claim shall be maintained by the third party administrator for a minimum of 30 years following the date of the claimant's separation from department employment.
      2. Each affected division/facility/school shall provide for retention of any medical surveillance records for 30 years following the date of separation of the employee from department service. Such medical records shall be confidential in nature and shall not be received or stored within the department.
      3. Any medical record shall be made available to the affected employee or his/her authorized representative within 15 working days of written request. Provision shall be performed by the third party administrator or medical care provider (as appropriate), and such records shall not pass into the keeping of department employees at any time.
    7. Other DHHS Safety and Health policies which require the creation of records not specified here shall state the accessibility and the retention period of such records.
  2. Acceptable written requests for records covered by this policy shall contain the following information. Any release of medical information will comply with the requirements of the DHHS Privacy Policies.
    1. The requester's name.
    2. Proof that the requester is a designated representative of the employee, if applicable.
    3. The date of the request.
    4. The record or records requested, including the year the record was generated, if applicable.
    5. If the request is on behalf of a former employee, the dates of employment with the department.
  3. A copy of records shall be provided to a duly authorized agent of the North Carolina Commissioner of Labor as designated:
    1. The OSHA 300, OSHA 300A, and/or any Industrial Commission Form 19 for the year of request or for any or all of the five (5) years preceding the year of request, as soon as possible following a verbal request by any compliance officer conducting an active inspection, or within the timeframe established in a written request from the NCDOL Research and Policy Division or Bureau of Planning, Statistics, and Information Management. A request for any of these records older than five (5) years from the date of request shall require approval from the DHHS Safety Program Manager.
    2. The current division/facility/school DHHS Hazardous Substance List and any Material Safety Data Sheet (MSDS) for any substance on the list, as soon as possible following a verbal request of any compliance officer conducting an active inspection of the division/facility/school.
    3. Any employee exposure record, including any MSDS for inactive substances, within 24 hours of verbal request by a compliance officer conducting an active inspection of the division/facility/school.
    4. Any training certification for the year preceding the request, and any training package, within 24 hours of verbal request by a compliance officer conducting an active inspection of the division/facility/school. Any request for these records older than one (1) year from the date of request shall require approval from the Safety Program Manager.
    5. Any medical record maintained on behalf of the department and in compliance with OSHA standards, within 24 hours of receipt of one of the following from a compliance officer conducting an active inspection of the division/facility/school:
      1. At least two (2) copies of a written access order and accompanying cover letter signed by the NC Commissioner of Labor, the Deputy Commissioner for Occupational Safety and Health, or a Chief of the Bureau of Compliance, which complies with the requirements of 29 CFR 1913.10. The cover letter and the copy of the written access order with employee-identifying information removed shall then be immediately posted for 15 days in a location where all affected employees may view it.
      2. A written authorization from the affected employee which contains the employee's name and signature, the date of authorization, the name of the compliance officer to whom the information is to be released, the specific records to be released, and the date the authorization will expire.
      3. Any request for medical records without the required documentation shall require approval from the DHHS Safety Program Manager.
    6. Any other document generated by the DHHS Safety and Health Program or its implementation within six (6) months of the date of inspection, will be provided as soon as possible to the compliance officer conducting an active inspection of the division/facility/school. Requests for documents older than six (6) months prior to the date of request shall require approval by the DHHS Safety Program Manager.

Definitions

See DHHS Establishment of the Safety and Benefits Policy, Establishment of the Safety and Health Program, Definition Section.

  1. Designated Representative - any individual or organization to whom an employee gives written authorization to exercise a right of access.
  2. Exposure Record - a record containing any of the following:
    1. Environmental monitoring, or measuring of a toxic substance or harmful physical agent, including personal, area, grab, wipe, or other form of sampling, as well as related collection and analytical methodologies, calculations, and other background data relevant to the results obtained.
    2. Biological monitoring results which directly assess the absorption of a toxic substance or harmful physical agent by body systems, excluding results which assess the biological effect of a substance or agent or which assess an employee's use of a controlled substance.
    3. MSDS indicating that the material may pose a hazard to human health.
    4. Canceled confined space entry permits where cancellation occurred due to an increase in chemical or biological exposure.
  3. Medical Record - a record containing the health status of an employee which is made or maintained by a medical care provider.
    1. Such records include:
      1. Medical and employment questionnaires or histories.
      2. Results of medical examinations and laboratory tests, excluding the opinion of the medical care provider letters.
      3. Medical opinions, diagnoses, progress notes, and recommendations.
      4. First aid records.
      5. Descriptions of treatments and prescriptions.
      6. Employee medical complaints.
    2. Such records do not include:
      1. Physical specimens which are routinely discarded as part of normal medical practice.
      2. Records concerning health insurance claims if maintained separately from medical records and not accessible to the department by employee name or direct personal identifier.
      3. Records created solely in preparation for litigation which is privileged from discovery.
      4. Records concerning voluntary employee assistance programs, if maintained separately from medical records.
  4. Record - any item, collection, or grouping of information regardless of the form or process by which it is maintained.

Implementation

  1. Each affected division/facility/school shall develop and implement procedures to provide for storage and retention of records under their jurisdiction.
  2. Safety and health records with a retention schedule defined by this policy shall be marked with the date of creation and the required retention period.
  3. In the event that a division/facility/school is absorbed, reorganized, or dissolved, it shall become the responsibility of the absorbing division/facility/school or of the DHHS Safety Program Manager, whichever is the most appropriate, to assume responsibility for records retention of the records covered by this policy.

References

North Carolina General Statutes:

  1. Chapter 95: Occupational Safety and Health Act of North Carolina: 95-129(2) and 95-148(4)
  2. Chapter 95, Article 18: Hazardous Substances Right to Know

North Carolina Administrative Code: 25 NCAC 1N.0105(i)

Superfund Amendments and Reauthorization Act, Title III

North Carolina Occupational Safety and Health Standards for General Industry:

  1. 29 CFR 1904: Recording and Reporting Occupational Injuries and Illnesses
  2. 29 CFR 1913.10: Rules of Agency Practice and Procedure Concerning OSHA

Access to Employee Medical Records:

  1. 29 CFR 1910.1020: Access to Employee Exposure and Medical Records

North Carolina State Employees’ Workplace Requirements Program for Safety and Health, Section 2:

  1. Policy 2.2: Requirements 1.a.
  2. Policy 2.8

For questions or clarification on any of the information contained in this policy, please contact Human Resources. For general questions about department-wide policies and procedures, contact the DHHS Policy Coordinator.


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