Blood Pathogen Policy



Purpose and Scope

  • The primary purpose of the Blood Pathogen Policy is to assure, so far as possible, safe and healthful
    working conditions a Plymouth State University. The focus of the Blood Pathogen Policy will be to prevent or reduce the risk of
    on-the-job exposure to blood-borne diseases. While there are many blood-borne diseases, the primary concerns are Hepatitis B Virus
    (HBV) and Human Immunodeficiency Virus (HIV).
  • The Blood Pathogen Policy is mandated and written as per University System Policy, USY V.D.
  • The policy will include:
    • Exposure control: Exposure Control Plan
    • Exposure determination
    • Methods of compliance
    • HBV vaccination
    • Post-exposure evaluation and follow-up
    • Training
    • Record-keeping


  • BLOOD — Means human blood, human blood components, and products madefrom human blood.
  • BLOOD-BORNE PATHOGENS — Pathogenic microorganisms that are present in humans. These pathogens
    include, but are not limited to, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).
  • CONTAMINATED — The presence or the reasonably anticipated presence ofblood or other potentially infectious materials on an item or surface.
  • CONTAMINATED SHARPS — Any contaminated object that can penetrate the skin,including, but not limited to: needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
  • ENGINEERING CONTROLS — Controls (e.g., sharps disposal containers, self sheathing needles) which isolate or remove the blood-borne pathogen hazard from the workplace.
  • EXPOSURE INCIDENT — A specific eye, mouth, other mucous meMEHane,non-intactskin, or parenteral contact with blood or otherpotentially infectious materials from the performance of theemployee’s
  • HBV — Hepatitis B Virus
  • HIV — Human Immunodeficiency Virus
  • OCCUPATIONAL EXPOSURE — Reasonably anticipated skin, eye, mucous meMEHane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.

Other potentially infectious materials

  • Any and all human body fluids.
  • Any unfixed tissue or organ(other than intact skin) from a human (living or dead).
  • HIV-containing cell or tissue cultures, organ cultures, and HIV or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from
    experimental animals infected with HIV or HBV.
  • PARENTERAL — A situation in which mucous meMEHanes or the skin barrier is pierced through an event such as a needle stick, human bite, cut, and abrasion.
  • PERSONAL PROTECTIVE EQUIPMENT — Specialized clothing or equipment worn by an employee for protection
    against a hazard i.e. eye goggles, face shields, gloves.
  • SOURCE INDIVIDUAL — Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee.
  • UNIVERSAL PRECAUTIONS — An approach to infection control. According to the concept of Universal Precautions, all blood and certain human body fluids are treated as if known
    to be infectious for HBV, HIV, and other blood-borne pathogens.
  • WORK PRACTICE CONTROLS — Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting the recapping of needles by a
    two-handed technique).

Exposure Control Plan

Exposure Determination

  • Job classifications which posea day to day potential occupational exposure include, but are not limited to:
  • Public Safety/Security Personal
  • Safety Officer
  • Health/Physical Ed Personnel
  • Health Services Personnel

Job classifications which pose a secondary occupational exposure include, but are not limited to:

  • All first aid certified employees
  • Any person who may respond and administer first aid . Health/Physical Ed Personnel
  • Student Affairs Personnel
  • Physical Plant Personnel
  • Child Development Center Personnel

Tasks and procedures where occupational exposure occurs include:

  • First aid response (e.g.,contact with body fluids, body contact)
  • Cleaning procedures involving body fluids/parts

Methods of Compliance

  • Universal Precautions will beused in all tasks where there is any possibility of exposure to blood or body fluids. All body fluids will be assumed to be contaminated with blood-borne pathogens.
  • Engineering and work practice controls shall be used to minimize or eliminate exposure. Each procedure shall be evaluated to determine the safest and most effective means of
    reaching the desired outcome. Work practice controls will be evaluated on a regular basis to ensure compliance and effectiveness of the procedure.
  • Engineering controls will be examined and maintained or replaced on a regular schedule to ensure their effectiveness (e.g., replacement of sharps containers….).
  • Readily available hand washing facilities will be provided for all personnel where practicable.
  • Employees shall wash their hands, or use an approved antiseptic wipe, until hand washing is possible, immediately after removal of gloves or other personal protective equipment. Any areas of skin which
    have come in contact with blood or other potentially infectious materials shall be washed with soap and water immediately or as soon as feasible. Exposed mucous meMEHanes shall be flushed immediately with water.
  • Contaminated sharps shall not be bent, recapped or removed unless it can be demonstrated that there is no feasible alternative or such action is required by a specific procedure. Recapping or removal must
    be accomplished using a mechanical device or a one-handed method.
  • Contaminated sharps shall be placed in an approved, recognizable, labeled, leak proof, puncture resistant, sharp container immediately after use or as soon as is feasible.
  • Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in ALL work areas where there is likelihood of occupational exposure.
  • Food and drink shall not be stored in or on refrigerators, freezers, shelves, cabinets, countertops, or bench tops where blood or other potentially infectious materials are present.
  • All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.
  • Mouth pipetting and suctioning of blood or other potentially infectious materials is prohibited.
  • Specimens of blood or other potentially infectious materials shall be placed in a labeled, leak proof container during collection, handling, processing, storage, transport, or shipping.
  • If there is a possibility of puncture, the primary container must be placed within secondary containment which is puncture resistant and properly labeled.
  • Contaminated equipment must be examined prior to shipping or servicing and shall be decontaminated as necessary unless it can be demonstrated that decontamination is not feasible. The portion which remains
    contaminated shall be labeled, and this information conveyed to all affected personnel.

Personal Protective Equipment

  • Provision — In those areas where there is occupational exposure, personal protective equipment (PPE) will be provided at no extra cost to the employees. PPE shall include, but
    not be limited to: gloves, gowns, laboratory coats, face shields or masks and eye protection and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.
  • PPE 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, undergarments, skin, eyes,
    mouth, or other mucous meMEHanes under normal conditions of use and duration of time the PPE will be used.
  • In the event an incident occurs where an employee does not use appropriate PPE, the circumstances shall be investigated and documented to determine whether changes can be instituted to prevent
    further occurrences.
  • Accessibility — Appropriate PPE in the appropriate sizes will be readily accessible in the areas where occupational exposure is likely to occur.

Repair and Replacement

  • PPE will be repaired or replaced as needed to maintain its effectiveness.
  • If the protective barrier provided by PPE has been breached by blood or other potentially infectious materials, it shall be removed immediately or as soon as feasible.
  • All PPE shall, prior to employees leaving the work area, be placed in a designated area for laundering, storage, or disposal.


  • Disposable latex gloves will be worn for all procedures where it can be reasonably anticipated that there will be contact with blood, other potentially infectious materials, mucous meMEHanes, and
    non-intact skin, and when touching contaminated items or surfaces.
  • Gloves shall be replaced after each use, or patient, and when their ability to function as a barrier is compromised. Contaminated, used, or breached gloves shall be disposed of in the specified manner.

Masks, Eye
Protection, Face Shields

  • Masks, in combination with eye protection, such as goggles or glasses with side shields, or chin-length face shields, shall be worn whenever splashes, spray, splatter, or droplets of blood or other
    potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonably be anticipated.

Gowns, Aprons, and Other Protective Clothing

  • Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, or clinic jackets, shall be worn in situations where occupational exposure may occur. The type and characteristics
    will depend upon the task and degree of exposure anticipated.
  • Surgical caps, hoods, and/or shoe covers or boots shall be worn in situations where gross contamination can be anticipated.


  • The workplace shall be maintained in a clean and sanitary condition. An appropriate written schedule for cleaning and decontamination shall be implemented. The procedures) will be based
    upon the location within the facility, type of surface to be cleaned, type of contamination, and tasks or procedures being performed in the area.
  • All equipment and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.
  • Appropriate Environmental Protection Agency (EPA) approved disinfectants shall be used for cleaning surfaces immediately, or as soon as feasible, when they have been contaminated, and at the end of
    the shift if contamination may have occurred since the last cleaning. Latex gloves must be worn when cleaning/decontaminating equipment, work surfaces and supplies. Materials used
    for decontamination shall be disposed properly
  • All receptacles which are intended for reuse shall be inspected and decontaminated on a regularly scheduled basis and decontaminated immediately, or as soon as feasible, upon
    visible contamination.
  • Broken glassware which may be contaminated shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps. Cleanup materials
    (brushes, forceps, etc.) used for picking up contaminated or potentially contaminated materials shall be properly disinfected or disposed of after use. All contaminated
    materials must be placed in an approved receptacle and disposed properly.

Hepatitis B Vaccination

  • Hepatitis B vaccine and vaccination series will be recommended to all employees who have occupational exposure. Post-exposure evaluation andfollow-up
    will be available to all employees who have had an exposureincident.
  • All required medical evaluations and procedures, vaccination series and post-exposure evaluation and follow-up shall be performed at no cost to the employee by a licensed physician or health care
    professional at a reasonable time and place.
  • All required laboratory tests will be conducted by an accredited laboratory at no cost to the employee.


Post Exposure Evaluation and Follow Up

Immediately following a report of an exposure incident, the exposed employee will be given a confidential medical evaluation and follow-up, including:

  • documentation of the routes) of exposure
  • circumstances of the exposure incident
  • identification of source individual, unless it can be established that this is infeasible or prohibited by state or local law
  • the source individual’s blood shall be tested as soon as possible, after consent is obtained, to determine HBV or HIV infectivity

    when the source individual’s blood is known to be infected with HBV or HIV, source testing need not be repeated
  • results of the source individual’s testing shall be available to the employee. The employee shall be informed of all applicable laws and regulations concerning disclosure of identity and infectious
    status of source individual.

Collection/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 serological 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.

All post-exposure employees will have access to the following services:

  • post-exposure health care measures
  • counseling
  • evaluation of reported illness

Information Provided to Health Care Professional

The following information shall be provided to the health care professionals responsible for the employee’s hepatitis B vaccination and/or post-exposure follow-up:

  • a copy of 29 CFR 1910.1030
  • a description of exposed employee’s duties, as related to the exposure incident
  • documentation of exposure routes and circumstances of exposure
  • results of source individual’s blood testing, if available
  • all medical records relevant to employee’s treatment, including vaccination status

Health Care Professional’s Written Opinion

The employee shall be given a
copy of the evaluating health care professional’s written opinion within 15 days of
completion of the evaluation.

The written opinion shall be limited to whether hepatitis B vaccination is indicated and whether the employee has received such.

The written opinion for post-exposure evaluation and follow-up shall be limited to the following:

  • employee has been informed of the evaluation results
  • employee has been informed about medical conditions resulting from exposure to blood or other potentially infectious material which requires further evaluation or treatment
  • All other findings or diagnoses shall remain confidential and not included in the written report.

Information and Training

Communication of Hazards to Employees

  • Fluorescent orange or red-orange BIOHAZARD labels shall be affixed to all containers of regulated waste, refrigerators, and freezers containing blood or other potentially infectious material. Red
    bags or red containers may be substituted for labels.


All employees with potential to occupational exposure to blood or other potentially infectious materials will participate in a training program.The training shall be provided as follows:

  • at the time of initial assignment to tasks where occupational exposure may take place
  • at least annually there after within one year of previous training

Additional training shall be provided when tasks or procedures are modified so as to affect employee occupational exposure.

Training shall be appropriate in content and educational level, literacy, and language of employees.

The training program will include, but not limited to, the following:

  • An accessible copy of the text of the 29 CFR 1910.1030, and an explanation of its contents
  • A general explanation of the epidemiology and symptoms of blood-borne diseases
  • An explanation of the modes of transmission of blood-borne pathogens
  • An explanation of the exposure control plan and access to a copy of the plan
  • An explanation of appropriate methods of recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials
  • An explanation of use and the limitations of personal protective equipment, engineering controls, and work practices
  • Information on the types, proper use, location, removal, handling, decontamination, and disposal of PPE
  • An explanation of the basis for selection of PPE
  • Information on the hepatitis B vaccine, including its efficacy, safety, method of administration, benefits of vaccination, and the fact that it will be recommended.
  • Information on appropriate action and contact persons in the event of an emergency involving blood or other potentially infectious materials
  • An explanation of the exposure incident procedure, including incident reporting and the medical follow-up which will be made available
  • Information on post-exposure evaluation and follow-up procedures that the employer is required to provide following an exposure incident
  • An explanation of the labeling requirements
  • An opportunity for interactivequestions and answers with the training instructor

Record Keeping

Medical records: An accurate record for each employee with occupational exposure will be established and maintained at PSU. This record will include:

  • name and social security number
  • a copy of employee’s hepatitis B status, including the dates of all 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
  • the employer’s copy of the health care professional’s written opinion
  • a copy of the information provided to the health care professional


Employee records shall:

  • be kept confidential
  • not be disclosed or reported, without the employee’s express written consent, to any person within or outside the workplace except as required by law
  • The employee’s records regarding occupational exposure to blood-borne pathogens shall be maintained by PSU for at least the duration of employment plus 30 years

Training Records

Training records shall include the following information:

  • dates of the training sessions
  • contents or summary of training sessions
  • names and qualifications of training instructor
  • names and job titles of all persons attending training sessions
  • Training records shall be maintained for 3 years from the date on which the training occurred. These records shall be part of each employee’s safety training file maintained by the campus compliance

Availability of Records

All records required to be maintained by federal regulations set forth in 29 CFR 1910.1030 shall be made available to the Assistant Security of Labor for Occupational Safety and Health, and to the Director of
the National Institute of Occupational Safety and Health and Human Services, upon request, for examination and copying.

Employee training records required by 29 CFR 1910.1030(h)(2) shall be provided to employees and to employee representatives for examination and copying upon request.

Employee medical records required by 29 CFR 1910.1030(h)(1) shall be provided to the subject employee and/or to anyone having written consent of the subject employee for examination and copying upon

Adopted by ________________________________, President of Plymouth State University, on this
______________ (day) of_________________ (month) _________(year). Effective immediately
unless otherwise amended.


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