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Bloodborne Pathogen Exposure Control Plan

RCC Facilities developed in accordance with the OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030


  • Purpose
  • Responsibility
  • Engineering & Work Practice Controls
  • Housekeeping
  • Other Regulated Waste
  • Laundry Procedures
  • Personal Protective Equipment
  • Hepatitis B Vaccine
  • Post-Exposure Evaluation & Follow-Up
  • Training
  •  
    Purpose: The purpose of this exposure control plan is to eliminate or minimize employee occupational exposure to 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.
    Responsibility: Departmental supervisors shall be responsible for ensuring their employees comply with the provisions of this plan. The Facilities Department is responsible for providing all necessary supplies such as personal protective equipment, soap and bleach, etc.  The cost of the Hepatitis B vaccinations shall be the responsibility of the college.  The Facilities Department shall be responsible for training department personnel in proper disposal of biohazardous waste contained in biohazardous waste bags.
    Engineering and Work Practice Controls: Universal/Standard Precautions will be observed by all Facilities Department 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.

Engineering and work practice controls will be utilized to eliminate or minimize exposure to all RCC employees.

  1. 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).**
  2.  
  3. Employees must wash their hands immediately (or as soon as feasible) after removal of gloves or other personal protective equipment.**
  4. **Employees shall familiarize themselves with the nearest hand washing facilities for the buildings in which they work. Because most RCC 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, the Facilities Department will provide 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 feasible.)

  5. Facilities Department employees who encounter improperly disposed needles shall notify the appropriate authorities at the location. Needles shall be disposed in labeled sharps containers provided at location. If sharps containers are not available at location, properly trained staff will pick up and dispose of needles in appropriate, labeled sharps container.
    • Needles should never be recapped.
    • Needles may be moved only by using a mechanical device or tool (forceps, pliers, broom and dust pan).
  6. Breaking or shearing of needles is prohibited.
  7. 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.
  8. 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.
  9. 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.

Housekeeping: Decontamination will be accomplished by utilizing the following materials:
    • 10% (minimum) solution of chlorine bleach
    • Lysol or other EPA-registered disinfectants
  1. 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.
  2. Equipment which may become contaminated with blood or other potentially infectious materials will be examined and decontaminated before servicing or use.
  3. Broken glassware will not be picked up directly with the hands. Sweep or brush material into a dustpan.
  4. 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 the Facilities Department.
  5. 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.
  6. 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: 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 or contents during handling, storage, or transport.

Biohazard bags and labels are available through the Facilities Department office.

Incineration of biohazardous waste shall be handled by a biological waste destructor. This shall be coordinated through a private contractor.


Laundry Procedures: 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.

The Facilities Department shall coordinate cleaning or disposal of contaminated laundry.


Personal Protective Equipment: Where occupational exposure remains after institution of engineering and work controls, personal protective equipment shall also be utilized.

The Physical Plant will provide gloves, face shields, eye protection, and aprons at no cost to employees. The Physical Plant will replace or repair personal protective equipment as necessary at no cost to employees.

All 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.

Employees must:

  • 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.

Hepatitis B Vaccine: 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 medical reasons.

If the employee initially declines Hepatitis B vaccination but at a later date decides to accept the vaccination, the vaccination shall then be made available.

All employees who decline the Hepatitis B vaccination offered shall sign the OSHA required waiver indicating their refusal.

If a 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.

The Hepatitis B Vaccine shall be offered to all staff in the following job categories:

  • Facilities
  • Child care
  • Physical education
  • Science
  • Allied health
  • Cafeteria
  • Automotive
  • Welding

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.

Following a report of an exposure incident, the exposed employee shall be directed to the nearest medical facility capable of performing a confidential medical evaluation and follow-up, including at least the following elements:

  1. Documentation of the route(s) of exposure.
  2. A description of the circumstances under which the exposure occurred.
  3. 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.)
  4. The collection and testing of the source individual's blood for HBV and HIV serological status.
  5. Post-exposure treatment for the employee, when medically indicated in accordance with the U.S. Public Health Service.
  6. Counseling.
  7. Evaluation of any reported illness.

The Healthcare professional evaluating an employee will be provided with the following information:

  1. A copy of this plan.
  2. A copy of the OSHA Bloodborne Pathogen regulations (29 CFR 1910.1030)
  3. Documentation of the route(s) of exposure.
  4. A description of the circumstances under which the exposure occurred.
  5. Results of the source individual's blood testing, if available.
  6. All medical records applicable to treatment of the employee, including vaccination status.

The employee will receive 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 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:

  1. That the employee was informed of the results of the evaluation.
  2. That the employee was informed about any medical conditions resulting from exposure to blood or other infectious materials that require further evaluation or treatment.
All other findings or diagnoses will remain confidential and will not be in a written report.

All 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 1910.20.


Training: 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.

Any employee who is exposed to infectious materials shall receive training, even if the employee was allowed to receive the HBV vaccine after exposure.

The training program will include at least the following elements:

  1. An accessible copy of the regulatory text of 29 CFR 1910.1030 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. An explanation of the employer's exposure control plan and the means by which the employee can obtain a copy of the written plan.
  5. An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood or 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, decontamination, and disposal of personal protective equipment.
  8. An explanation of the basis for selection of personal protective equipment.

<< Section 1: Bloodborne Pathogens Introduction Section 3: Bloodborne Diseases >>