Bloodborne Pathogens Standard
Exposure Control Plan
Hendrix College - September 2018
Bloodborne Pathogens Standard, codified at 29 CFR § 1910.1030, was promulgated
by the U.S. Department of Labor's Occupational Safety and Health Administration
(OSHA). This standard applies to
employers with a history of employee exposure or those who can reasonably
anticipate that one or more of their employees, as part of their job duties,
will have exposure to human blood or other potentially infectious body fluids
(including cleaning and disposing of any wastes generated during an incident).
implementation of this bloodborne pathogens policy is intended to reduce or
eliminate employee exposure to bloodborne pathogens and comply with the OSHA
Bloodborne Pathogens Standard. This
standard in no way extends an employee's liability to treat an injury or
provide first aid to a fellow employee or student. It simply outlines safety procedures to be
followed in the event that a situation in which exposure to potentially
infectious body fluids is encountered during the course of an employee’s duties
as defined by their job description.
bloodborne pathogens standard requires employers to develop and implement a
written exposure control plan that
is designed to eliminate or minimize employee exposure to bloodborne
pathogens. This exposure control plan
must contain methods of implementation for each element of the standard. It must be made available to employees, OSHA,
and NIOSH upon request. The exposure
control plan must be reviewed and updated annually. Failure to comply with this
OSHA standard can result in penalties for each citation.
Hendrix College employees affected by this
standard are outlined below.
Potential for exposure
- Cleaning and/or
repair of contaminated surfaces
- Cleaning of
- Cleaning of
- First Aid and/or cleaning
of contaminated surfaces
employees working in any of these classifications also require training
the college’s Director of Student Health and athletic trainers are designated
to render first aid as part of their primary job assignment. No other employees have first-aid,
first-responder or emergency medical treatment responsibilities.
OSHA requires that this plan include methods of
implementation for the various requirements of the standard. The employer must take appropriate
preventative measures against an exposure incident which is defined by
the OSHA standard as specific eye, mouth, other mucous membrane, non-intact
skin, or parenteral contact with blood or OPIM.
College these include the
following controls to reduce or eliminate such exposure.
Precautions": Universal body
substance avoidance precautions must be observed to prevent contact with blood
or other potentially infectious materials.
Practicing universal precautions involves handling all blood and body
fluids as though they were infected with human
immunodeficiency virus (HIV) or hepatitis
B virus (HBV). All blood or OPIM
will be considered infectious regardless of the perceived status of the source
Engineering controls are those controls that remove the
hazard or isolate the employee from exposure.
The following controls shall be
used to eliminate or minimize employee exposure. Where occupational exposure remains after
institution of these controls, personal
protective equipment (PPE) shall also be used. These are designed for small
incidents where soap and water, disinfectant cleaners, gloves and isolation
materials may not be readily available.
PPE kits and replacement items are available for all employees through
the Chemical Compliance Office and can be found in Reynolds Hall, room
216. Hendrix College
provides hand washing facilities which are readily accessible to
employees. OSHA requires that these
facilities be readily accessible after incurring exposure. If hand washing
facilities are not readily available, the employer is required to provide
either an antiseptic cleanser in conjunction with a clean cloth/paper towel or
antiseptic towlettes. If these
alternatives are used the hands are to be washed with soap and running water as
soon as feasible.
Work Practice Controls
Work practice controls are policies, procedures and
techniques which reduce the likelihood of exposure through the alteration of
the manner in which the task is performed.
Disposable (single-use) latex gloves shall be worn whenever it can
reasonably be anticipated that the employee may have mucous membrane,
non-intact skin, or parenteral contact with blood or other potentially
infectious materials. Hypoallergenic
gloves, glove liners, powderless gloves, or other similar alternatives must be
provided to those employees who are allergic to the gloves normally
provided. Gloves must be removed prior
to leaving the immediate work area and must be replaced as soon as practical
when they become contaminated or as soon as feasible if they are torn,
punctured, or when their ability to function as a barrier is compromised. They are not to be reused. If any PPE is contaminated with blood or OPIM
they shall be disposed of in a closable, leak proof container for disposal in a
lined waste container that protects other employees from direct physical
contact. Hands must be washed immediately or as soon as feasible after removal
of gloves. Employees must wash hands and
any other potentially contaminated skin area with soap and water, or flush
mucous membranes with water immediately or as soon as feasible following
contact of such body areas with blood or other potentially infectious
materials. All garments which are
penetrated by blood shall be removed immediately or as soon as feasible and
should be contained or isolated in a manner that protects other employees from
direct physical contact.
All equipment and working surfaces shall be cleaned and
decontaminated after contact with blood or OPIM. Small amounts of blood or other potentially
infectious materials can be removed with an absorbent towel. Contaminated surfaces shall be decontaminated
with an appropriate disinfectant. Larger
amounts of blood or OPIM may require methods employed by the housekeeping staff
which include the use of protective gloves and disinfectants (see Appendix B).
Surfaces within food preparation areas may be decontaminated with a 10%-50%
solution of household bleach. Broken glassware or other sharps such as
hypodermic needles which may be contaminated shall not be picked up directly
with the hands. They shall be cleaned up using mechanical means, such as a
brush and dust pan, tongs, or forceps.
Contaminated sharps shall be discarded immediately or as soon as
feasible in a sharps container specified for such disposal.
College shall make available the hepatitis B vaccination series to all
employees who: 1) Are required by virtue of their job
classification to attend bloodborne pathogen training, or 2) has, during
the course of their job duties, been in any situation involving the
presence of blood or OPIM in the workplace regardless of whether an actual
exposure incident occurred, even if their job classification did not
previously place them at risk. Everyone
in this job classification would then be added to the list of covered
provisions will be made available at no cost to the employee at a
reasonable time and place under the supervision of a licensed physician or
other licensed healthcare professional according to the recommendations of
the U.S. Public Health Service current at the time these evaluations and
procedures take place. The
hepatitis B vaccination series is currently offered on campus and administered
by the Student Health Nurse on campus.
who decline the hepatitis B vaccine will sign a waiver which uses the
exact wording in Appendix A of the OSHA standard.
- All exposure
incidents must be reported to the Chemical Compliance Director before the
end of the work shift during which the exposure incident occurred.
Procedures For Exposure Incidents
Following all incidents or events where an employee
has during the course of assigned job duties had an actual exposure incident
as defined by the standard, a report must be made to the employee's
direct supervisor. All reports will
be forwarded to and maintained by the Chemical
Compliance Director (Shelly Bradley, 450-3812)
report shall indicate the names of the persons involved, the date and time
of the incident, and a determination of whether any employees incurred
exposure to blood or OPIM.
report shall indicate that the employee was advised to consult with a
physician or other licensed healthcare professional concerning additional
precautions such as the post-exposure hepatitis B vaccine. The report will
then indicate the intentions of the employee to receive or decline further
medical treatment or consultation. A signed waiver will indicate an
employee's intentions to decline further treatment.
Medical Evaluation and Follow-up of Exposure
Following the determination of an exposure incident, Hendrix College shall make immediately available
to the exposed employee a confidential medical evaluation and follow-up
including at least the following elements:
of the route(s) of exposure, and the circumstances related to the
and documentation of the source individual, unless the employer can
establish that identification is infeasible or prohibited by state or
local law. The source individual's
blood shall be tested as soon as feasible and after consent is obtained in
order to determine HBV and HIV infectivity. If consent is not obtained, the employer
shall establish that legally required consent cannot be obtained. When the source individual's consent is
not required by law, the source individual's blood, if available, shall be
tested and the results documented.
When the source individual is already known to be infected with HBV
or HIV, testing for the source individual's known HBV or HIV status need
not be repeated. Results of the
source individual's testing shall be made available to the exposed
employee, and the employee shall be informed of applicable laws and
regulations concerning disclosure of the identity and infectious status of
the source individual.
exposed employee's blood shall be collected as soon as feasible and tested
after consent is obtained. If the
employee consents to baseline blood collection, but does not give consent
at that time for HIV serologic testing, the sample shall be preserved for
at least 90 days. If, within 90
days of the exposure incident, the employee elects to have the baseline
sample tested, such testing shall be done as soon as feasible.
prophylaxis, when medically indicated, as recommended by the U. S. Public
Health Service will be offered to the employee.
College shall ensure that
the healthcare professional evaluating an employee after an exposure incident
is provided the following information:
- A copy
of the OSHA standard.
description of the exposed employee's duties as they relate to the
of the route(s) of exposure and circumstances under which exposure
of the source individual's blood testing, if available
medical records relevant to the appropriate treatment of the employee
including vaccination status which are the employer's responsibility to
The employer shall obtain and provide the employee with a
copy of the evaluating healthcare professional's written opinion within 15 days
of the completion of the evaluation. The
healthcare professional's written opinion for hepatitis B vaccination shall be
limited to whether hepatitis B vaccination is indicated for an employee, and if
the employee has received such vaccination.
The healthcare professional's written opinion for post-exposure
evaluation and follow-up shall be limited to an indication that the employee
has been informed of the results of the evaluation and that the employee has
been told about any medical conditions resulting from exposure to blood or
other potentially infectious materials which require further evaluation or
treatment. All other findings or
diagnoses shall remain confidential and shall not be included in the written
Hazards to Employees
The employer shall ensure that all employees with
occupational exposure participate in a training program which must be provided
at no cost to the employee and during working hours. Training shall be provided at the time of
initial employment and at least annually thereafter. Annual training for all employees shall be
provided within one year of their previous training. Employers shall provide additional training
when changes such as modification of tasks or procedures or institution of new
tasks or procedures affect the employee's occupational exposure. The additional training may be limited to
addressing the new exposures created.
Material appropriate in content and vocabulary to educational level,
literacy, and language of employees shall be used. The training program shall contain at a
minimum the following elements:
accessible copy of the regulatory text of the OSHA standard for bloodborne
pathogens and an explanation of its contents.
general explanation of the epidemiology and symptoms of bloodborne
explanation of the modes of transmission of bloodborne pathogens.
- A copy
of this exposure control plan and an explanation of its contents.
explanation of the appropriate methods for recognizing tasks and other
activities that may involve exposure to blood and other potentially
explanation of the use and limitations of methods that will prevent or
reduce exposure including appropriate engineering controls, work
practices, and personal protective equipment.
on the types, proper use, location, removal, handling, and disposal of
personal protective equipment.
on the post-exposure hepatitis B vaccine and information on its efficacy,
safety, method of administration, benefits, and availability.
on the appropriate actions to take and persons to contact in an emergency
involving blood or other potentially infectious materials.
explanation of the procedure to follow if an exposure incident occurs,
including the method of reporting the incident.
- An explanation
of the signs, labels, and color coding related to the Bloodborne Pathogen
Standard as required by 29 CFR §
on medical follow-up, as required by 29 CFR §
an exposure incident.
opportunity for interactive questions and answers with the person
conducting the training session.
The person conducting the training shall be knowledgeable in the
subject matter covered by the elements contained in the training program
as it relates to the workplace that the training will address.
College shall establish
and maintain an accurate record for each employee with an actual exposure
incident. This record shall include:
name and social security number of the employee.
- A copy
of all incident reports involving the employee
- A copy
of the employee's hepatitis B vaccination status including the dates of
all the hepatitis B vaccinations and any medical records relative to the
employee's ability to receive vaccination.
- A copy
of all results of examinations, medical testing, and follow-up procedures.
employer's copy of the healthcare professional's written opinion.
- A copy
of the information provided to the healthcare professional.
College shall ensure that
employee medical records are kept confidential and are not disclosed or
reported without the employee's express written consent to any person within or
outside the workplace except as required by this standard or as may be required
by law. Employee medical records
required by this section shall be provided upon request for examination and
copying to the subject employee, to anyone having written consent of the
subject employee, to the Director, and to the Assistant Secretary. Hendrix
College shall maintain
the records for at least the duration of employment plus 30 years
Training records shall include the following information:
dates of the training session.
contents or a summary of the training session.
names and qualifications of persons conducting the training.
names and job titles of all persons attending the training sessions.
Training records shall be maintained for three years from
the date on which the training occurred.
Employee training records required by this section shall be made
available upon request for examination and copying to employees, to employee
representatives, to the Director, and to the Assistant Secretary.
College shall comply with
the requirements involving transfer of records set forth in 29 CFR § 1910.1020(h). If Hendrix College ceases to do business and
there is no successor employer to receive and retain the records for the
prescribed period, it shall notify the Director, at least three months prior to
their disposal and transmit them to the Director, if required by the Director
to do so, within that three-month period.
Literature used to prepare this bloodborne pathogens policy.
Occupational Exposure to Bloodborne Pathogens, Federal
Register, Code of Federal Regulations Volume 29, section 1910.1030.
Laboratory Health and Safety. R. Scott Stricoff and Douglas
B. Walters, 2nd edition, John Wiley & Sons, Inc., New York, NY
Bloodborne Pathogens in the Workplace, Robert J. Morris and
Mark Upfal, Genium Publishing Corporation, Schenectady, NY, 1994.
Bloodborne Pathogens Standard: OSHA Between the Lines, Ian
Moar, Compliance Magazine, March 1996, pp. 6-9.
Bloodborne Pathogens: A Risk Management Prospective, Michael
D. Leggett, Network News, Volume 7, No. 3, December 1993, pp. 1-9.