Bloodborne Pathogen Exposure Control Plan
Reviewed August 2014
Revised December 2013
in accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030
The purpose of this exposure control plan is to eliminate or minimize employee
occupational exposure to human blood or other infectious body fluids. Other potentially
infectious body fluids include: semen, vaginal secretions, cerebrospinal fluid, synovial
fluid, pleural fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and
any body fluid visibly contaminated with blood.
This Standard applies to all University personnel who, during the course
of their employment, may come into contact with human blood or potentially
infectious body fluids.
Departmental supervisors and foremen shall be responsible for ensuring their employees
comply with the provisions of this plan. Each University department is responsible for providing
all necessary supplies such as personal protective equipment, soap, bleach, Hepatitis B
vaccinations, etc. Most of these supplies are available from the Physical Plant Supply
Department. Hepatitis B vaccinations shall be administered through OSU's University Health Services. The Environmental Health and Safety Department shall be responsible for training
University employees and for disposing of biohazardous waste contained in biohazard
Universal precautions will be observed by all employees in order to prevent
contact with blood or other potentially infectious materials. All blood or other
potentially infectious materials will be considered infectious regardless of the perceived
status of the source individual.
The OSU Environmental Health & Safety Department shall solicit input from all non-managerial OSU employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls.
and work practice controls will be utilized to eliminate or minimize exposure to all employees working at Oklahoma State University.
- Employees must wash their hands or other skin with soap and water,
or flush mucous membranes with water, as soon as possible following an exposure incident
(such as a splash of blood to the eyes or an accidental needle stick). **
must wash their hands immediately (or as soon as feasible) after removal of gloves or
other personal protective equipment.**
shall familiarize themselves with the nearest hand washing facilities for the buildings in
which they work. Because most OSU buildings are public access, they will have available
hand washing facilities in public restrooms and custodial / janitorial closets. (If hand
washing facilities are not available, each department will provide its workers either an antiseptic
cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. If these
alternatives are used, then the hands are to be washed with soap and water as soon as
- University employees who encounter
improperly disposed needles shall notify EHS of the location of the needle(s).
Additionally, the appropriate authorities at the location shall be notified (i.e. lab
manager, head resident). Needles shall be disposed of in labeled sharps containers
provided at the location. If sharps containers are not available at that location, EHS
will pick up and dispose of the needles in an appropriate, labeled sharps container.
Breaking or shearing of needles is prohibited.
No eating, drinking, smoking, applying cosmetics or lip balm, or
handling contact lenses is allowed in a work area where there is a reasonable likelihood
of occupational exposure.
No food or drinks shall be kept in refrigerators, freezers, shelves,
cabinets, or on counter tops or bench tops where blood or other potentially infectious
materials are present.
Employees must perform all procedures
involving blood or other potentially infectious materials in such a manner as to minimize
splashing, spraying, splattering, and generation of droplets of these substances.
should never be recapped.
- Needles may be moved only by using a mechanical device or tool (forceps, pliers, broom and dust pan).
Decontamination will be accomplished by utilizing the following materials:
All contaminated work surfaces, tools, objects, etc. will be
decontaminated immediately or as soon as feasible after any spill of blood or other
potentially infectious materials. The bleach solution or disinfectant must be left in
contact with contaminated work surfaces, tools, objects, or potentially infectious
materials for at least 10 minutes before cleaning.
Equipment that may become contaminated
with blood or other potentially infectious materials will be examined and decontaminated
before servicing or use.
Broken glassware will not be picked up directly with the hands.
Sweep or brush material into a dustpan.
Known or suspected contaminated sharps shall be discarded
immediately or as soon as feasible in containers that are closeable, puncture-resistant,
leak-proof on sides and bottom, and marked with an appropriate biohazard label. If sharps
container is not pre-labeled, biohazard labels are available through EHS.
When containers of contaminated sharps are being moved from the area
of use or discovery, the containers shall be closed immediately before removal or
replacement to prevent spillage or protrusion of contents during handling, storage,
transport, or shipping.
Reusable containers shall not be opened,
emptied, or cleaned manually or in any other manner that would expose employees to the
risk of percutaneous injury.
Other regulated waste shall be placed in containers that are closeable, constructed to contain all contents and prevent leakage of fluids during handling, storage, transportation or shipping.The waste must be labeled or color coded and closed before removal to prevent spillage or protrusion of contents during handling, storage, or transport.
Biohazard bags and labels are available through the EHS department office.
Incineration of biohazardous waste shall be handled by a biological waste destructor. This shall be coordinated through the EHS department if pre-existing disposal arrangements have not already been made through University Health Services or the Seretean Wellness Center.
Laundry contaminated with blood or other potentially infectious material will be handled
as little as possible. Such laundry will not be sorted or rinsed in the area of use.
coordinate cleaning or disposal of contaminated laundry.
Where occupational exposure remains after institution of engineering and work controls,
personal protective equipment shall also be utilized.
Each University department will provide gloves, face shields, eye protection, and aprons to
employees and will replace or repair personal protective equipment as
necessary, all at no cost to their employees.
personal protective equipment will be chosen based on the anticipated exposure to blood or
other potentially infectious materials. The protective equipment will be considered
appropriate only if it does not permit blood or other potentially infectious materials to
pass through or reach the employee's clothing, skin, eyes, mouth, or mucous membranes
under normal conditions of use and for the duration of time for which the protective
equipment will be used.
- Utilize protective equipment in occupational exposure situations.
- Remove garments that become penetrated by blood or other potentially infectious material immediately or as soon as feasible.
- Replace all garments that are torn or punctured, or that lose their ability to function as a barrier to bloodborne pathogens.
- Remove all personal protective equipment before leaving the work area.
- Place all garments in the appropriate designated area or container for storage, cleaning, decontamination, or disposal.
The Hepatitis B vaccination shall be made available after the employee has received the
training in occupational exposure and within 10 working days of initial assignment. It
shall be made available to all employees who have potential occupational exposure unless
the employee has previously received the complete Hepatitis B vaccination series, antibody
testing has revealed that the employee is immune, or the vaccine is contraindicated for
If the employee initially declines Hepatitis B vaccination but at a
later date decides to accept the vaccination, the vaccination shall then be made
employees who decline the Hepatitis B vaccination offered shall sign the OSHA required waiver indicating their refusal.
routine booster dose of Hepatitis B vaccine is recommended by U.S. Public Health Service
at a future date, such booster doses shall be made available at no cost to the employee.
Hepatitis B Vaccine shall be offered to all University personnel who, during the course of their employment and regular job duties, may come into contact with human blood or potentially infectious body fluids.
Post Exposure Evaluation and Follow-up
All exposure incidents shall be reported, investigated, and documented. When the employee
incurs an exposure incident, it shall be reported immediately to their supervisor. All exposure incidents involving the use of sharps (or any percutaneous procedure) shall be recorded in the Sharps Injury Log, which will be kept for a minimum of five years.
report of an exposure incident, the exposed employee shall go to University Health Services
for a confidential medical evaluation and follow-up, including at least the following
Documentation of the route(s) of exposure
A description of the circumstances under which the exposure
occurred. If the exposure involved the use of sharps (or any percutaneous procedure), this description must include the following:
The identification and documentation of the source individual (The
identification is not required if the employer can establish that identification is
impossible or prohibited by state or local law.)
The collection and testing of the source individual's blood for HBV
and HIV serological status
Post-exposure treatment for the employee, when medically indicated
in accordance with the U.S. Public Health Service
Evaluation of any reported illness
- A. The type and brand of the device involved in the incident.
- B. The department or work area where the exposure occurred.
- C. An explanation of how the incident occurred.
Healthcare professional evaluating an employee will be provided with the following
A copy of this plan.
A copy of the OSHA Bloodborne Pathogen regulations (29 CFR
Documentation of the route(s) of exposure.
A description of the circumstances under which the exposure
Results of the source individual's blood testing, if available.
All medical records applicable to treatment of the employee,
including vaccination status.
employee will receive a copy of the evaluating healthcare professional's written opinion
within 15 days of the completion of the evaluation.
healthcare professional's written opinion for Hepatitis B vaccination is limited to the
following: (1) whether the employee needs Hepatitis B vaccination; (2) whether the
employee has received such a vaccination. The healthcare professional's written opinion
for post-exposure evaluation and follow-up is limited to the following information:
That the employee was informed of the results of the evaluation.
That the employee was informed about any medical conditions
resulting from exposure to blood or other infectious materials that require further
evaluation or treatment.
other findings or diagnoses will remain confidential and will not be in a written report.
medical evaluations shall be made by or under the supervision of a licensed physician or
by or under the supervision of another licensed healthcare professional. All laboratory
tests must be conducted by an accredited laboratory at no cost to the employee. All
medical records will be kept in accordance with 29 CFR 1910.1020.
All high risk employees shall participate in a training program. Training will occur
before assignment to a task where occupational exposure may take place and at least
annually thereafter. Additional training will be provided when changes such as
modification of tasks or procedures affect the employee's occupational exposure.
who is exposed to infectious materials shall receive training, even if the employee was
allowed to receive the HBV vaccine after exposure.
training program will include at least the following elements:
An accessible copy of the regulatory text of 29 CFR 1910.1030 and an
explanation of its contents.
A general explanation of the epidemiology and symptoms of bloodborne
An explanation of the modes of transmission of bloodborne pathogens.
An explanation of the employer's exposure control plan and the means
by which the employee can obtain a copy of the written plan.
An explanation of the appropriate methods for recognizing tasks and
other activities that may involve exposure to blood or other potentially infectious
An explanation of the use and limitations of methods that will
prevent or reduce exposure, including appropriate engineering controls, work practices,
and personal protective equipment.
Information on the types, proper use, location, removal, handling,
decontamination, and disposal of personal protective equipment.
An explanation of the basis for selection
of personal protective equipment.
that due to my occupational exposure to blood or other infectious materials that I may be
at risk of acquiring Hepatitis B virus infection. I have been given the opportunity to be
vaccinated with the Hepatitis B vaccine at no charge to myself. However, I decline the
Hepatitis B vaccination at this time. I understand that by declining this vaccine, I
continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I
continue to have occupational exposure to blood or other potentially infectious materials
and I want the Hepatitis B vaccine, I can receive the vaccination series at no charge to
End of Manual