Chemical Compliance

Hendrix College Bloodborne Pathogen Exposure Control Plan

Bloodborne Pathogens Standard
Exposure Control Plan
Hendrix College - September 2000

The 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 employment duties, will have exposure to human blood or other potentially infectious body fluids (including cleaning and disposing of any wastes generated during an incident ). The regulation states that an employer must follow all parts of the standard if even one employee has potential exposure to blood and body fluids as part of their job.

The 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. Compliance with 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.

The 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. Additional information related to the campus exposure control plan can be obtained through the Hendrix web page directory under Chemical Safety.

Failure to comply with this OSHA standard can result in penalties for each citation. OSHA records from October 1998 through September 1999, indicate a total of 1233 citations in the American workplace totaling $853,165 in proposed fines. 

Exposure Control Plan 

Exposure Determination

OSHA requires employers to perform an exposure determination ascertaining which employees may incur occupational exposure. Occupational exposure is defined by the OSHA standard as reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials (OPIM). This exposure determination is required to include a listing of all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. All Hendrix College employees in the following job classifications have the potential for exposure to bloodborne pathogens: teaching faculty, physical plant, dining service, student development, and student employees working in these classifications. The potential for exposure exists as a result of the supervision of student activities in classrooms, laboratories, studios, theaters, athletic fields, residence and dining halls, and on off-campus trips. No college employees are designated to render first aid as part of their primary job assignment nor does any employee have first-responder or emergency medical treatment responsibility. Occupational exposure of employees within the specified classifications is limited to collateral duty that may exist when responding to workplace incidents. One exception to this classification is the Director of Student Health who is covered under the plan of another employer, Conway Regional Medical Center.

Methods of Compliance

OSHA requires that this plan also include a schedule and method 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. At Hendrix College these include the following controls to reduce or eliminate such exposure.


 "Universal 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 individual. 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. PPE kits include a pair of latex gloves, cleaning towel, disinfectant towlette, and an antiseptic towlette which are contained in a zip-lock bag to be used for disposal of contaminated items. PPE kits and replacement items are available for all employees through the Chemical Compliance Office and can be found in Reynolds Hall, room 404.

Engineering Controls

Engineering controls are those controls that remove the hazard or isolate the employee from exposure. 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 then the hands are to be washed with soap and running water as soon as feasible. Antiseptic towlettes will be provided to all employees and additional or replacement towlettes can be obtained whenever required from the campus Chemical Compliance Office.

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 be reasonably anticipated that the employee may have hand contact with blood, mucous membranes, non-intact skin, 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 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. Gloves must be removed prior to leaving the work area. They shall be placed in a closable, leakproof container (Ziploc bag) 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 is consistent with the previously mentioned universal precautions. 

Cleaning Contaminated Surfaces

All equipment and environmental working surfaces shall be cleaned and decontaminated after contact with blood or OPIM. Contaminated surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures. Small amounts of blood or other potentially infectious materials can be removed using the components of the PPE kits. However, larger amounts 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.

Post-exposure Hepatitis B Vaccine

Hendrix College shall make available the hepatitis B vaccine and vaccination series to all employees who have rendered assistance in any situation involving the presence of blood or OPIM in the workplace regardless of whether an actual exposure incident occurred. Additionally, Hendrix College will make available a post-exposure evaluation, prophylaxis and follow-up to all employees who have experienced an exposure incident as defined by the standard.

  • These 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.
  • All first-aid incidents must be reported to the Chemical Compliance Director before the end of the work shift during which the first aid incident occurred. Any unvaccinated employee who has incurred possible exposure to blood or OPIM shall be provided the hepatitis B post-exposure vaccination series as soon as possible and no later than 24 hours after the incident.
  • Employees who decline the hepatitis B vaccine will sign a waiver which uses the exact wording in Appendix A of the OSHA standard.
Reporting Procedures For First Aid or OPIM Incidents

Following all first aid incidents or events where an employee has rendered assistance in any situation involving the presence of blood or OPIM, a report must be made to the Chemical Compliance Director or the employee's direct supervisor. All reports will be forwarded to and maintained by the Chemical Compliance Director (Mark Smith, 450-3812)

  • The 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.
  • The 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 the post-exposure hepatitis B vaccination as well as their intent to seek further medical treatment or consultation. A signed waiver will indicate an employee's intentions to decline the hepatitis B vaccination.
Medical Evaluation and Follow-up of Exposure Incidents

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:

  1. Documentation of the route(s) of exposure, and the circumstances related to the incident.
  2. Identification 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.
  3. Collection and testing of blood for HBV and HIV serological status. The 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.
  4. Post-exposure prophylaxis, when medically indicated, as recommended by the U. S. Public Health Service will be offered to the employee.
  5. Counseling. The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident.
  6. Evaluation of reported illnesses. The employee will also be given information on what potential illnesses to be alert for and to report any related experiences to appropriate personnel.

Hendrix College shall ensure that the healthcare professional responsible for the employee's hepatitis B vaccination is provided a copy of the OSHA standard.

Hendrix College shall ensure that the healthcare professional evaluating an employee after an exposure incident is provided the following information:

  1. A copy of the OSHA standard.
  2. A description of the exposed employee's duties as they relate to the exposure incident.
  3. Documentation of the route(s) of exposure and circumstances under which exposure occurred.
  4. Results of the source individual's blood testing, if available
  5. All medical records relevant to the appropriate treatment of the employee including vaccination status which are the employer's responsibility to maintain.

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 report.

Communication of 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:

  1. An accessible copy of the regulatory text of the OSHA standard for bloodborne pathogens and an explanation of its contents.
  2. A general explanation of the epidemiology and symptoms of bloodborne diseases.
  3. An explanation of the modes of transmission of bloodborne pathogens.
  4. A copy of this exposure control plan and an explanation of its contents.
  5. An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
  6. 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.
  7. Information on the types, proper use, location, removal, handling, and disposal of personal protective equipment.
  8. Information on the post-exposure hepatitis B vaccine and information on its efficacy, safety, method of administration, and availability.
  9. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
  10. An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident.
  11. An explanation of the signs, labels, and color coding related to the Bloodborn Pathogen Standard as required by 29 CFR 1910.1030(g)(2)(vii)(M)
  12. Information on medical follow-up, as required by 29 CFR 1910.1030(g)(2)(vii)(K), following an exposure incident.
  13. An 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.
Employee Records

Hendrix College shall establish and maintain an accurate record for each employee with occupational exposure. This record shall include:

  1. The name and social security number of the employee.
  2. A copy of all incident reports involving the employee
  3. 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.
  4. A copy of all results of examinations, medical testing, and follow-up procedures.
  5. The employer's copy of the healthcare professional's written opinion.
  6. A copy of the information provided to the healthcare professional.

Hendrix 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:

  1. The dates of the training session.
  2. The contents or a summary of the training session.
  3. The names and qualifications of persons conducting the training.
  4. The 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.

Hendrix 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.

Appendix A

Training Documentation for Hendrix College


My signature below certifies that I received Bloodborne PathogenTraining presented by Shelly Bradley and I understand how to protect myself from these hazards.


You will only fill out ONE of the sections below. 

Fill out section one if you do NOT wish to receive the Hepatitis B Vaccine series of three shots.  Fill out section two if you have already received the Hepatitis B Vaccine series of three shots or you plan to start them immediately.


Section 1

Hepatitis B Vaccine Declination

 Standard Number: 1910.1030 App A

 Standard Title: Hepatitis B Vaccine Declination (Mandatory)

 SubPart Number: Z

 SubPart Title: Toxic and Hazardous Substances


Produced by USDOL OSHA - Directorate of Safety Standards & Directorate of Health Standards

Maintained by USDOL OSHA - OCIS


I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection.  I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself.  However, I decline 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 to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.


[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb. 13, 1996]


Printed Name                                                           Signature                                                                   Date


_________________________________         __________________________________         ______________



Section 2

I have already received the hepatitis B vaccination series of three shots at a previous time or I plan to start the series immediately at the following location:     (Please check one)

                                                                     Hendrix College


                                                                     Location other than Hendrix College


Printed Name                                                          Signature                                                                  Date


_________________________________         __________________________________         ______________

Appendix B

Additional Decontamination Procedures


All cleaning and removal of blood or other potentially infectious material from environmental surfaces should be done while wearing latex gloves. Any blood or other body fluids, including saliva, semen and vomit should be considered infectious. Most gross contamination can be removed with the proper use of PPE kits that are provided to each housekeeping employee. If large amounts of blood require additional blotting with Wypals, dispose of the contaminated towels in a bag that can be tied closed and then placed in a second lined trash container. If mopping is required for removal, ready-to-use disinfectant can be applied and removed using a mop and mop bucket. After gross contamination has been removed, the surface can be decontaminated with a mixture of Quat 128 or Quat 256. The disinfectant should remain on the surface for 10 minutes to allow adequate time for the elimination of HBV or HIV.

References: 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 1995.
  • 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.

Incident Report

Bloodborne Pathogens Exposure Control Plan

This report is in compliance with 29 CFR 1910.1030 (f)(3) and CPL Directive 2.2-44c

Appendix B concerning documentation of first-aid and exposure incidents.

Date of Incident: _______________          Time (approximate) of incident: _______________
Name of employee(s) involved in incident:
Description of incident:





Did an exposure occur?

An exposure is defined by the OSHA standard as specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials (OPIM).

Name of source individual (if applicable):

Were universal precautions followed by all employees in direct contact with blood or OPIM ?

Were all employees advised of medical consultation and precautionary treatment that is available to them as a result of possible exposure incurred while rendering assistance in the incident reported above? Signatures verify employee was advised of available medical treatment.


Signature of Employee(s)                                      Signature of employee(s) supervisor


________________________                                ____________________________


Date/Time: ________________                             Date/Time: ________________


Signature of Campus Chemical Compliance Director




Date/Time: ________________