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Exposure Control Plan
Brown University’s Institutional Biosafety Committee, along with the Office of
Environmental Health and Safety, has developed a template Exposure Control Plan (ECP) for all
Biological Research Authorizations and Biological Safety Manuals.
The Laboratory Supervisor must read the ECP template and carefully fill out key
components specific to the protocol in which it belongs. In some cases one ECP may be
thorough enough to be used for more than one protocol however, ALL ECP’s must be reviewed
and updated annually and when necessary (i.e., a change of agent, procedure, location, or
staff).
Please contact Brown University’s Biological Safety Officer for assistance at 401-863-3353.
Created: November 2011
Reviewed: June 2012
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Exposure Control Plan (ECP)
POLICY
Brown University is committed to providing a safe and healthful work environment for faculty, students, and staff. In
pursuit of this goal, the following Exposure Control Plan (ECP) is provided to assist researchers in developing procedures
to eliminate or minimize occupational exposure to biological hazards and bloodborne pathogens in accordance with the
Institutional Biosafety Committee (IBC) and OSHA standards. This ECP includes:
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Determination of researcher exposure
Implementation of various methods of exposure control, including:
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Universal precautions
Engineering and administrative controls
Personal protective equipment
Hepatitis B vaccination
Disinfection/sterilization
Housekeeping
Post-exposure evaluation and follow-up
Recordkeeping
Communication of hazards to visitors/contractors and training
Implementation methods for these elements of the standard are discussed in the subsequent pages of this ECP.
Please Note: Where biological research is conducted with hazardous chemicals, the Chemical Hygiene Plan and Lab
Safety Manual shall be used according to the policies discussed in Laboratory Safety Training.
PROGRAM ADMINISTRATION
The Laboratory Supervisor (listed below) is responsible for implementation of the ECP in location(s) covered by the plan,
will maintain, review and update the ECP at least annually, and whenever necessary to include new or modified tasks
and procedures.
Laboratory Supervisor Name/Research Location:
Title of the protocol covered by this ECP:
Authorization number of the protocol covered by this
ECP:
Contact Number (include area code):
Created: November 2011
Reviewed: June 2012
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24-Hour Contact Number (mobile/home):
IMPORTANT! All procedures associated with the specific Biological Research Authorization for which this ECP has been
created must be attached along with the ECP (i.e., cell culture procedures, injection procedures, etc.)
RESEARCER EXPOSURE DETERMINATION
The following is a list of all laboratory personnel who perform tasks and procedures in which occupational exposure may
occur and who must comply with all provisions outlined in this Exposure Control Plan.
Name/Job Title (example: John Smith,
Research Asst.)
Department/Laboratory Location
(example: MCB/BMC 864)
Task/Procedure where occupational
exposure may occur (example: Cell
injection in live mice)
METHODS OF IMPLEMENTATION AND CONTROL
Universal Precautions
Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human
blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne
pathogens.
Even when working with biological substances believed not to be infectious, researchers shall use universal precautions.
Exposure Control Plan Training
Created: November 2011
Reviewed: June 2012
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In addition to completion of Brown University EHS Biological Safety Training and Bloodborne Pathogen (BBP) Training,
researchers shall read and understand the specific ECP for the protocol on which they are assigned.
Engineering Controls and Administrative Controls
Engineering controls and administrative controls will be used to prevent or minimize exposure to biological materials
and bloodborne pathogens. Whenever possible, select and utilize engineering controls and administrative controls that
mitigate exposure such as, but not limited to:
 Appropriate Biosafety Cabinets
 Non-glass capillary tubes
 Sharps with Engineered Sharps Injury Protections (SESIP’s)
 Needleless systems
 Personal protective equipment
Administrative controls are defined as: controlling workplace hazards through methods such as training, written
operating procedures, work permits, safe work practices, exposure time limitations, alarms, signs, and warnings.
The specific engineering controls and administrative controls used as part of this research protocol are listed below:
Engineering Controls
Administrative Controls
Created: November 2011
Reviewed: June 2012
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Sharps containers shall be replaced before they become overfilled to prevent needle sticks. Sharps must fit completely
into the selected sharps container (i.e., not to exceed the manufacturers marked "full" line). Do not bend, break, re-cap,
or re-sheath any needle. Do not force or push any item into a sharps container. When the fill line is reached, sharps
containers must be closed and locked (all sharps containers come with a locking mechanism). Requests for full sharp
container pick-up and replacement containers supplied by Environmental Health and Safety can be made through the
Container Request form located at the following URL:
http://brown.edu/Administration/EHS/container_disposal/
Personal Protective Equipment (PPE)
Describe below, the appropriate PPE that will be used for specific tasks or procedures. (Examples: Nitrile gloves shall be
used for handling specimens preserved in formaldehyde, splash goggles will be worn while performing blood draws on
mice etc.) Remember, a minimum level of PPE must be worn in the lab at all times i.e., safety glasses and appropriate
clothing.
PPE
Task/Procedure
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All researchers using PPE must observe the following precautions:
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Remove gloves carefully to avoid spraying or spatter
Wash hands immediately or as soon as feasible after removing gloves or other PPE.
Remove PPE after it becomes contaminated and before leaving the work area
For proper disposal of PPE please refer to the Brown University Biological Waste Program found at the following
URL:
http://brown.edu/Administration/EHS/policies/biological_waste_program.pdf
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Wear appropriate gloves when it is reasonably anticipated that there may be hand contact with blood or OPIM,
and when handling or touching contaminated items or surfaces; replace gloves if torn, punctured or
contaminated, or if their ability to function as a barrier is compromised
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Never wash or decontaminate disposable gloves for reuse.
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Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a
hazard to the eye, nose, or mouth
Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to
avoid contact with the outer surface
If utility gloves are being used, dispose if contaminated
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Vaccination/Screening Program
Are there any non-routine measures such as special vaccinations or additional health screening techniques that would
potentially benefit research staff participating in or supporting this project?
___ No.
___ Yes. If yes, describe___________________________________________________________________________
_______________________________________________________________________________________________.
Disinfection and Sterilization
Disinfection and sterilization is important for any Biological Research or Biological Waste Disposal. To choose an
appropriate disinfectant, the identity of the micro-organisms, their concentration and the degree of inactivation desired
should be considered. Physical factors such as whether a space or surface is to be decontaminated, the type of surface,
and any interaction between the material and potential disinfectants should also be factored in the selection. Time
available for disinfection and the time required for particular disinfectants to be effective need to be considered. For
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clarification, “disinfection” is not sporicidal. A few disinfectants will kill spores with prolonged exposure times (3-12
hours) and are called “chemical sterilants.”
Factors that may affect the efficacy of chemical disinfectants include the following:
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Organic and inorganic load present
Type and level of microbial contamination
Concentration of and exposure time to the germicide
Physical nature of the object (e.g., crevices, hinges etc.)
Presence of biofilms
Temperature and pH of the disinfection process
In some cases, relative humidity of the sterilization process
Most disinfectant solutions need to be regularly prepared as fresh solutions to avoid growth of micro-organisms in the
solution and to ensure optimum activity of the disinfectant chemical.
Remember to don proper PPE including chemically resistant gloves while performing disinfection.
If using commercial disinfectants, Federal law requires all applicable label instructions on EPA-registered products to be
followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use, and disposal). If the user selects exposure
conditions (e.g., exposure time) that differ from those on the EPA-registered products label, the user assumes liability
for any injuries resulting from off-label use and is potentially subject to enforcement action under Federal Insecticide,
Fungicide, and Rodenticide Act (FIFRA) 65.
Disinfection Tool (Table 1):
In order to ensure proper on-site disinfection techniques, the office of Environmental Health and Safety (EHS) has
created a disinfection tool which is included in every Exposure Control Plan specific to the agent/space for which it is
developed. All University researchers, staff and students involved in biological research or with occupational exposure
to bloodborne pathogens must reference this chart before engaging in a protocol, disposing of, storing, or transporting
within a building biological materials or bloodborne pathogens.
http://www.brown.edu/Administration/EHS/restricted/disinfection_tool.docx
Using the Disinfection Tool (Table 1):
For all biological materials, wastes, and bloodborne pathogens encountered, the users of an Exposure Control Plan must
indicate which disinfectant or sterilant they intend to use along with the recommended dilution, contact time, pH and
temperature. A reference in which this disinfectant was recommended must be included in the column labeled
“REFERENCE.” If using an EPA-registered or commercial product for disinfection/sterilization please also indicate the
name of this product along with its recommended dilution, contact time, pH and temperature (in the disinfection table
provided). If utilizing steam sterilization, indicate the settings used i.e., time, temperature and pressure. A good
resource for this information is the “Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008” from the
Centers for Disease Control (CDC). To obtain a list of Selected EPA-registered Disinfectants visit:
http://www.epa.gov/oppad001/chemregindex.htm
Attachments to this table may be included.
Created: November 2011
Reviewed: June 2012
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Spaces within the table that are shaded and marked “NR” refer to disinfectants that were specifically Not Recommended
for certain biological materials/wastes by either the CDC, World Health Organization (WHO) and/or the Brown University
Institutional Biosafety Committee. For example, the prions category marked with many “NR’s” were shown to have a
high innate resistance to many chemical germicides. In fact, proper chemical decontamination for prions as
recommended by the WHO include a combination heat and NaOH or for surfaces, by flooding for one hour, with NaOH
or sodium hypochlorite, followed by water rinses.
If in the course of your research you find conflicting support for disinfectants/sterilants that have been automatically
labeled as “NR” in the Disinfection Tool, please contact EHS at 401-863-3353 as it is possible that a product listed as
“NR” might be sufficient for the type of disinfection/sterilization you require.
Additionally, when using this tool please consider the exceptions and restrictions listed below.
Exceptions and Restrictions:
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Ethanol is not recommended for surface contamination due to the low contact time before evaporation
Bleach dilutions made be made fresh daily as the efficacy only last 24 hours
Formaldehyde is not a recommended disinfectant due to its carcinogenic properties and its Short Term
Exposure Limit (STEL) of 2ppm as set by OSHA.
Hydrogen peroxide can cause cosmetic and functional changes in equipment
UV radiation has several potential applications, but unfortunately its germicidal effectiveness and use is
influenced by organic matter; wavelength; type of suspension; temperature; type of microorganism; and UV
intensity, which is affected by distance. UV radiation is not recommended to disinfect surfaces because of lack
of penetration
The level of biocidal activity of Ortho-phthalaladehyde(OPA) was directly related to the temperature. 0.5% OPA
was not sporicidal with 270 minutes of exposure
Paracetic Acid and Hydrogen Peroxide can cause cosmetic and functional changes in equipment
Table 1 (SEE ATTACHMENT)
Housekeeping
An organized, clean laboratory is imperative for safety and good research. Maintenance of safety equipment (i.e.,
emergency eyewashes) is also an important factor in keeping a safe laboratory environment. Routine cleaning and
disinfection of all surfaces must be employed. Ensure that only cleanable, non-porous surfaces are used (i.e., fabric
chairs shall not be used in the lab).
Below, is a list of the routine cleaning/disinfection/maintenance procedures the lab will follow and their frequency:
(Example: 10% Bleach dilution, contact time 15 minutes, sprayed on bench tops, nightly)
Cleaning/Disinfection/Maintenance
Task/Procedure
Frequency
Created: November 2011
Reviewed: June 2012
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For a full description of disposal requirements for Biological Waste refer to:
http://brown.edu/Administration/EHS/policies/biological_waste_program.pdf
Laundry
Laboratory coats must be kept in the laboratory when not in use and should never be brought home for laundering.
Laboratory coats that have been heavily contaminated with biological agents, infectious substances, or hazardous
chemicals shall be replaced. Routine laundering of laboratory coats may be conducted in-house (if available) or by a
professional laundering service and approved vendor. Contact the Purchasing Department at 863-2206 for a list of
approved vendors.
List the types of items specific to this lab or this protocol that may require laundering or replacement when
contaminated:
Example: (Disposable lab coats, replaced after contamination)
Item
Replacement/Disposal/Laundering Frequency (if
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laundering, please specify where and how)
In addition, the following general laundering requirements must be met:
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Handle potentially contaminated laundry as little as possible, with minimal agitation
Place wet laundry in leak-proof and appropriately labeled containers before transport
Wear appropriate PPE when handling and/or sorting laundry
Labels and Door Signs
Any equipment or container contaminated with biological materials, bloodborne pathogens or OPIM must display the
universal Biohazard symbol i.e., biological sharps containers, vacuum flasks etc.
To be NIH compliant, this symbol must also appear on any door where Biosafety Level 1 or 2 (BSL 1 or 2) work occurs or
biological waste is held. Also required for a BSL-1 sign:
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Biosafety Level
Name of agent(s) in use
Name and phone number of lab supervisor
Required for a BSL-2 sign:
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Biosafety level
Laboratory supervisor’s name and telephone number
required procedures for entering and exiting the laboratory
Created: November 2011
Reviewed: June 2012
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The standard CEMS emergency contact door sign posted on every laboratory door should reflect this information. If
your current sign does not, contact EHS at 401-863-3353.
EMERGENCIES
In general, Brown University employees and students must not engage in spill response for hazardous substances such
as chemical, biological, and radioactive materials. However, in some situations, such as clean up of incidental spills (i.e.,
a few drops), it is appropriate for the person who caused the incidental spill to clean up the material but only if they
have been properly trained and have the appropriate equipment. All other spills must be reported to Brown University
Public Safety at 863-4111 so that the Environmental Health & Safety Emergency Response Team may be activated.
In the event of a hazardous substance emergency or spill, the following action should be taken:
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Immediately alert all personnel to evacuate the room.
Once everyone is out, close the door behind you.
Find a nearby phone and contact Brown University Public Safety at 863-4111.
Tend to injured or contaminated personnel.
Stay in the general area, at a safe distance away, and wait for emergency responders.
Introduce yourself to emergency responders as they arrive. Emergency responders want to ensure that the
information they have is accurate and that conditions have not changed since the initial phone call was made.
POST-EXPOSURE EVALUATION AND FOLLOW-UP
There are several types of exposure that could lead to injury or illness in faculty, staff and students:
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Parenteral-puncture from a sharp, animal bites
Mucous Membrane- contact through eyes, nose, mouth, inhalation
Non-intact Skin-cut/scrape, rash, cold sore, acne, hang nail
Should an exposure incident occur:
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Immediately wash area with soap and water, or in case of an eye exposure flush with copious amounts of water
use an emergency eyewash if available
Notify your supervisor
Contact public safety at 401-863-4111
-if minor/low risk exposure, report to EHS as an alternative to calling public safety
Seek first aid/medical treatment and always consult with a physician i.e., health services, your doctor etc.
For proper reporting use the forms found here:
http://www.brown.edu/Administration/EHS/lab/PDFs/accident_form.pdf
http://www.brown.edu/Administration/Office_of_Insurance_and_Risk/documents/Injury%20AR%20Form%20Rev.6%27
06.doc.pdf
Created: November 2011
Reviewed: June 2012
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RESEARCHER TRAINING
All researchers who have reasonably anticipated occupational exposure to biological materials, bloodborne pathogens,
or OPIM, or potentially dangerous equipment, shall receive task-specific/equipment-specific training conducted by the
Laboratory Supervisor or designee. The Laboratory Supervisor shall also ensure that task-specific/equipment-specific
training is appropriately documented.
Provide below tasks/procedures for which laboratory researchers will receive task-specific/equipment-specific training:
(Example: Cardiac puncture blood-draw on mouse, centrifuge training)
RECORDKEEPING
Training Records
Training for task-specific/equipment-specific training shall be documented. These documents will be kept (Insert
location of records here____________) for the duration of the Biological Research Authorization and any associated
Renewals/Amendments.
Created: November 2011
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The following training form template shall be used to document laboratory/equipment specific training:
http://www.brown.edu/Administration/EHS/restricted/supervisors_training_template.pdf
The training records include:
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Dates of the training sessions
Contents or a summary of the training sessions
Names and qualifications of persons conducting the training
Names and job titles of all persons attending the training sessions
Communication of Hazards
Informing Other Employers/Contractors
It is the responsibility of the Laboratory Supervisor to provide other employees and contractors with information about
hazardous chemicals, biological materials, bloodborne pathogens, and OPIM that employees maybe exposed to on a job
site along with suggested precautions and PPE.
Before scheduling service with an outside contractor, the equipment to be serviced must be decontaminated unless that
piece of equipment is being decontaminated by said outside contractor. In all events contractors or employees should
use Universal Precaution while servicing equipment in a Brown University Laboratory.
Laboratory Moving/Closeout Policy
The purpose of the Brown University Closeout Policy is to ensure that all Research Laboratories and Research Support
Areas are properly cleaned and decontaminated prior to decommissioning. Decommissioning of a laboratory or research
support area may be necessary when a Laboratory Supervisor leaves the University, transfers to another space, or when
a laboratory is prepared for demolition/renovation.
There are several resources available to assist Laboratory Supervisors and Departments with tasks related to the proper
decommissioning of research space. Some of these resources include, but are not limited to, the following:
• Office of Environmental Health & Safety at 863-3353
• Purchasing Department at 863-2206
• Facilities Management at 863-7800
More information on this policy can be located at the following URL:
http://www.brown.edu/Administration/EHS/restricted/lab_closeout.pdf
Created: November 2011
Reviewed: June 2012