Ohio Northern University
Exposure Control Plan
for
Bloodborne
Pathogens
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THE OSHA BLOODBORNE PATHOGENS STANDARD: SUMMARY
The OSHA "Occupational Exposure to Bloodborne Pathogens" (29 CFR Part1910.1030) is
applicable to employees with exposures to blood and other potentially infectious materials.
The standard defines an "occupational exposure" as reasonably anticipated skin, eye,
mucous membrane, 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"* include semen, vaginal secretions, cerebrospinal fluid, pleural fluid, pericardial
fluid, peritoneal fluid, amniotic fluid, saliva, any body fluid that is visibly contaminated with
blood, unfixed human tissue or organs, and cell cultures containing HIV or HBV. A
summary of the OSHA standard, found in the Code of Federal Regulations (29CFR)
1910.1030, is appended to this plan but summarized below.
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Employers must write an Exposure Control Plan designed to eliminate or minimize
employee exposures and must provide a copy to covered employees.
Employers must identify job classifications in which employees have occupational
exposures.
Standard Precautions are to be utilized in the handling of blood or other potential
infectious materials.
Engineering and work practice controls and personal protective equipment are to be
used to eliminate or minimize employee exposures.
Hepatitis B vaccine is to be offered to all employees with occupational exposures.
Post-exposure medical evaluation and follow-up is to be provided for employees
with occupational exposures;
Annual training must be provided for all employees with occupational exposures.
*CDC and OSHA do not list the following body fluids as HIV/Hepatitis B transmission
sources unless they contain blood: urine, feces, vomit, tears, sputum, sweat, or nasal
secretions. Other materials may be sources: any unfixed tissue or organ, other than intact
skin from a human, living or dead; HIV/Hepatitis B containing cell or tissue cultures, organ
cultures and culture media; blood, organs or other tissues from experimental animals
infected with HIV, Hepatitis B, or other bloodborne pathogen.
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I. Purpose and Scope
This Exposure Control Plan is established by Ohio Northern University (ONU) to document
the procedures intended to eliminate or minimize, and to prevent, when possible, the
exposure of ONU employees and students to disease-causing pathogens that may be
transmitted through human blood and certain body fluids, in accordance with the
Occupational Safety and Health Administration’s Bloodborne Pathogens Standard, 29 CFR
1910.1030.
The exposure control plan is a key document to assist the University in implementing and
ensuring compliance with the OSHA bloodborne pathogen (BBP) standard, thereby
underscoring the University’s commitment to providing a safe and healthful work
environment for all personnel.
The purpose of the Bloodborne Pathogens Standard is to reduce the potential of
occupational transmission of potentially infectious body fluids caused by microorganisms
sometimes found in human blood and certain other potentially infectious body fluids and/or
tissues. The OSHA Standard, found in the Code of Federal Regulations (29CFR)
1910.1030, is appended to this plan.
This plan covers all ONU employees and students who may be exposed to blood and other
potentially infectious materials (OPIM) during the performance of their job duties and/or
during school-associated activities. It is expected that all elements of this plan will be
adhered to by all employees and students of the University. This ECP includes:
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Determination of exposure
Implementation of methods of exposure control, including:
o Standard precautions
o Engineering and work practice controls
o Personal protective equipment
o Housekeeping
Hepatitis B vaccination
Post-exposure and follow-up
Communication of hazards to employees and students, and training
Recordkeeping
Procedures for evaluating circumstances surrounding exposure incidents
Implementation of this standard is discussed in the subsequent pages of this ECP.
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II. Glossary of Terms and Abbreviations
1. AIDS – acquired immunodeficiency syndrome.
2. Blood - human blood, human blood components, and products made from human
blood.
3. Bloodborne Pathogens (BBP) – pathogenic micro-organisms that are present in
human blood and can cause disease in humans. These pathogens include, but are not
limited to, Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV).
4. BPS – Bloodborne pathogen standard.
5. BSC – Biosafety Committee
6. CDC – Centers for Disease Control
7. CLS – Clinical Laboratory Science
8. Contaminated – the presence or the reasonably anticipated presence of blood or other
potentially infectious materials on an item or surface.
9. Decontamination – the use of physical or chemical means to remove, inactivate or
destroy bloodborne pathogens on a surface or item to the point where they are no
longer capable of transmitting infectious particles and the surface or item is rendered
safe for handling, use or disposal.
10. ECP – Exposure control plan
11. Engineering Controls – methods, equipment, and/ or procedures that isolate or
remove the bloodborne pathogens hazard from the workplace.
12. Exposure Incident - a specific eye, mouth, other mucous membrane, non-intact skin,
or parenteral contact with blood or other potentially infectious materials that results from
the performance of an employee's duties.
13. HBV – Hepatitis B Virus
14. HCV – Hepatitis C Virus
15. HIV – Human Immunodeficiency Virus
16. IRB – Institutional Review Board
17. Licensed Healthcare Professional - a person whose legally permitted scope of
practice allows him or her to independently perform the activities required by paragraph
(f) Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up.
18. NIOSH – National Institute for Occupational Safety and Health
19. Occupational Exposure - reasonably anticipated skin, eye, mucous membrane, or
parenteral contact with blood or other potentially infectious materials that may result
from the performance of an employee's duties.
20. Other Potentially Infectious Materials (OPIM) - (1) The following human body fluids:
semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial
fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is
visibly contaminated with blood, and all body fluids in situations where it is difficult or
impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other
than intact skin) from a human (living or dead); and (3) 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.
21. OSHA – Occupational Safety and Health Administration
22. Parenteral – piercing mucous membranes or the skin barrier through such events as
needlesticks, human bites, cuts and abrasions.
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23. PHS – Public Health Service
24. Personal Protective Equipment - specialized clothing and/ or equipment worn by an
employee for protection against a hazard. General work clothes (e.g., uniforms, pants,
shirts or blouses) not intended to function as protection against a hazard and are not
considered to be personal protective equipment.
25. Regulated Waste - liquids or semi-solid blood or other potentially infectious material; or
contaminated items that would release blood or other potentially infectious material in a
liquid or semi-liquid state if compressed; or items that are caked with dried blood or
other potentially infectious material and are capable of leaking this material during
handling.
26. Sharps – any contaminated object that can penetrate the skin, including but not limited
to needles, scalpels, scissors, blades, broken glass, and broken capillary tubes.
27. Source Individual - any individual, living or dead, whose blood or other potentially
infectious materials may be a source of occupational exposure to the employee.
Examples include, but are not limited to, hospital and clinic patients; clients in
institutions for the developmentally disabled; trauma victims; clients of drug and alcohol
treatment facilities; residents of hospices and nursing homes; human remains; and
individuals who donate or sell blood or blood components.
28. Standard Precautions – an approach to infection control in which all human blood and
certain human body fluids are treated as if known to be infectious for HIV, Hepatitis B
and other bloodborne pathogens.
29. Work Practice Controls – methods or procedures that reduce the likelihood of
exposure by altering the manner in which a task is performed, i.e., wearing gloves, eye
wear, etc.
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III. Program Management
Institutional Biosafety Committee
Certain activities within the University have the potential for employee and student
exposure to human blood and body fluids which may be sources of harmful and potentially
lethal diseases. To provide oversight for work and school-related activities in these areas,
the University has established an Institutional Biosafety Committee (IBC), a standing
subcommittee of the University Safety Committee.
The biosafety committee is comprised of the following individuals, appointed by the VP of
Academic Affairs:
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A.
Exposure Control Coordinator/Biosafety Committee Chair (Biosafety Officer);
Human Resources Director or designee;
Institutional Review Board Chairman;
Representative(s) of Biological & Allied Health Sciences
Representative of Student Affairs;
Representative of the College of Pharmacy;
Representative of University Security; and
Representative of Physical Plant.
Community Member
Community Member
The committee is charged with the following responsibilities:
1. Recommend policies to university administration that promote a healthful and
safe work environment; and
2. Serve as a resource and advise the university safety committee and
the institutional review board (IRB) regarding biosafety issues.
B. The ECP will be reviewed and/ or updated: (a) annually, (b) whenever new or modified
tasks and procedures are implemented which affect employee exposure, (c) whenever
changes in technology eliminate or reduce employee exposure to bloodborne
pathogens, and (d) whenever employees’ jobs are revised to include new tasks in which
exposure may occur. The reviews are performed by the BSC.
C. The annual review is intended to ensure that the ECP accurately reflects current federal
and state regulations, and applicable CDC and PHS and guidelines.
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Plan Coordinator
A.
The coordinator is charged with the following responsibilities:
1. Implementing the ECP;
2. Providing ECP training for all employees determined to have occupational
exposure to blood or OPIM as follows:
a.
b.
c.
d.
e.
f.
g.
h.
i.
Initial training provided within two (2) weeks of employment or reassignment to a job having potential exposure;
Annual training for all employees whose job position places them at risk of
potential exposure;
Documenting training, providing the human resources office with training
documentation, and making the written ECP available for distribution to
the university, OSHA and NIOSH representatives, and others as may be
required to comply with the standard;
Working with employees to develop and administer appropriate training of
students whose campus activities places them at risk of potential BBP
exposure;
Working with the biosafety committee, university administration,
employees, and other agencies to develop and administer any additional
policies and practices related to bloodborne pathogens, including those
specified by the Needlestick and Prevention Act;
Maintaining and updating the ECP at least annually and as required by the
BCP;
Representing the University during inspections and campus events
requiring input regarding biosafety;
Conducting periodic facility audits to identify the need for changes in
engineering and work practice controls and to maintain an up-to-date
ECP.
Reviewing the circumstances of all exposure incidents and maintaining a
log of injuries resulting from occupational exposures to bloodborne
pathogens, including sharps incidents.
Human Resources
A. The Human Resources Director or designee is responsible for:
1. Ensuring that all medical actions and training required by the standard are
performed and that appropriate employee health and training records are
maintained;
2. Distributing the ECP to University Administration, Services, Employees (full-time,
part-time, temporary, contract, per diem, and appointed), and Academic
Departments as required by the ECP;
3. Scheduling training required by the ECP with the Plan Coordinator;
4. Notifying employees of scheduled training.
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University Administration, Directors, Managers, Supervisors, Division and Department
Chairs
A. University Administration, Directors, Managers, Supervisors, Division and Department
Chairs are responsible for:
1. Implementing established policies and procedures regarding exposure control in
their respective areas. They work directly with employees to ensure that proper
exposure control procedures are followed.
2. Ensuring that all new employees receive education and/or training with respect to
the requirements of the ECP.
3. Annually sending a list of all employees who need training to the Office of Human
Resources.
Employees
A. Individual employees are key to successful implementation of the ECP. All employees
who are determined to have occupational exposure to blood and OPIM are to comply
with the procedures and work practices in the ECP. This includes but is not limited to:
1. Identifying which job tasks have potential for occupational exposure to blood,
body fluids or tissues;
2. Attending initial and annual training;
3. Routinely and consistently following safe work practices as defined by the ECP to
prevent exposure;
4. Practicing good personal hygiene habits without exception;
5. Immediately reporting all exposure incidents and sharp injuries to their supervisor
to assure documentation and treatment;
6. Discussing all concerns regarding the ECP with their supervisor.
7. Participating in opportunities to identify and select safer devices to use as
defined by the Needlestick and Prevention Act.
IV. Exposure Determination
A. All job categories where it is reasonable to anticipate that an employee may have
mucous membrane or parenteral contact with blood or other body fluids (those listed
below), are included in this ECP. Exposure determination is made without regard to the use
of PPE.
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Blood and Blood Products (e.g., plasma, serum, red cells, white cells, and
platelets)
Cerebrospinal Fluid
Serous Fluid (Pleural, Pericardial, and/ or Peritoneal)
Synovial Fluid
Amniotic Fluid
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Semen
Saliva
Vaginal Secretions
Any body fluid visibly contaminated with blood
Other potentially infectious materials as defined by CDC
B. OSHA standard 1910.1030 refers only to employees; however, the ONU ECP by design
includes students who are at risk of exposure due to their campus activities including
studies. These individuals are to receive appropriate instruction through the academic
department supervising their educational programs or work. All other employees, with
the exception of those listed below, have no expectation of occupational exposure to
blood or other potentially infectious body fluids.
1. The following is a list of all job classifications at ONU in which employees (Fulltime,
part-time, contract, and appointed) have anticipated occupational exposure.
a.
b.
c.
d.
Physician
Nurse
Phlebotomist
First aid responders who are:
1)
2)
3)
4)
Security Officers
Athletic Trainers
Life Guards
Safety Officers
e. Faculty and staff who are involved in academic programs in clinical laboratory
sciences, forensic science, nursing, pharmacy, and pre-professional areas.
2. The following is a list of job classifications in which some employees have possible
occupational exposure.
Job classification
Tasks with occupational exposure
Faculty/Non-faculty staff
collecting blood samples or OPIM, processing unfixed
tissues and blood specimens, antibody screening of
blood specimens, separation of blood components,
performing analytical tests on human blood and/ or blood
components, and unfixed tissues, resolution of
emergency/injury or illness incident
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Lab or animal technician
handling HBV and/ or HIV infected specimens and/ or
animals, collecting blood samples or OPIM, processing
unfixed tissues and blood specimens, separation of blood
components, setting up labs in which human blood and/
or blood components, and unfixed tissues are tested,
resolution of emergency/injury or illness incident
Laboratory manager
handles unfixed tissues and blood specimens, resolution
of emergency/injury or illness incident
Coach
student athlete instruction, resolution of emergency/injury
or illness incident
Plumber
Job classification
repairing plumbing/ drains across campus, resolution of
emergency/injury or illness incident
Tasks with occupational exposure
Groundskeeper
resolving personal injury/illness incident
Carpenter
repairing facility structures across campus, resolution of
emergency/injury or illness incident
General Maintenance Worker
making repairs and performing duties across campus,
resolution of emergency/injury or illness incident
Housekeeper
cleaning restrooms, collecting and transporting sharps
and
medical
waste
containers,
resolution
of
emergency/injury or illness incident
Secretary or Mail Clerk
delivering blood/tissue-containing packages, resolution of
emergency/injury or illness incident
Resident Assistant
resolution of emergency/injury or illness incident
V. Methods of Implementation and Exposure Control
ONU has an exposure control plan and employees covered by the bloodborne pathogens
standard receive an explanation of the ECP during their initial training. It is also reviewed in
their annual refresher training. All employees can review this plan at any time during their
work by contacting the Human Resources Office or the ECP coordinator.
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A. Standard Precautions
CDC isolation guidelines defines standard precautions as an approach to infection control
in which all human blood specimens, blood contaminated body fluids, or materials are
treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Standard Precautions may include the following practices:
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Wear gloves, masks and protective eyewear
Wear protective suits, gowns or aprons
Wash hands and other skin surfaces
Disinfect all contaminated surfaces
Use proper disposal
Use protective resuscitation masks for CPR
Use safety devices to prevent occupational exposure via sharps (needles, blades,
etc.)
B. Standard precautions are to be observed by all employees to prevent contact with
blood and/ or OPIM. Under circumstances in which differentiation between body fluids
types is difficult or impossible, all body fluids shall be considered potentially infectious
materials.
C. Standard precautions are intended to prevent exposure to human blood and/or OPIM.
The routes of transmission for occupational exposure are:
1. puncture of the skin with contaminated sharp objects
2. contact with broken skin
3. splash to mucous membranes of the eye, nose and/or mouth
D. Specific precautions are described below.
Engineering and Work Practice Controls – are used to eliminate or minimize
employee exposure to bloodborne pathogens. Sharps and biohazard waste
containers are inspected, maintained, or replaced as needed by primary users to
prevent overfilling. Containers are available by contacting the manager of the
university warehouse (extension 2580). Specific engineering controls and work
practices used are listed below:
1. Hand washing - hands and any other contaminated skin are to be washed
with soap and water, and mucous membranes flushed with water
immediately following contact of such body areas with blood or OPIM.
Employees shall familiarize themselves with the nearest hand washing
facilities for the buildings in which they work. Because most ONU 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, housekeeping will provide either an antiseptic cleanser in
conjunction with clean cloth/paper towels or antiseptic towelettes. If these
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alternatives are used, then the hands are to be washed with soap and
water as soon as feasible.)
2. Use of waste disposal containers: contaminated sharps e.g., (needles,
lancets, and scalpels etc.) are not to be bent, broken, or re-capped.
Sharps are to be disposed of in puncture resistant, leak-proof containers
displaying a BIOHAZARD label. Contaminated PPE and OPIM are to be
placed in biohazard-labeled cardboard containers lined with red bag liners.
a. Warning labels must be affixed to containers of regulated waste,
refrigerators and freezers containing blood or OPIM, and other
containers used to store, transport or ship blood or other potentially
infectious materials. Labels must include the biohazard symbol, and
be fluorescent orange or orange-red with lettering or symbols in a
contrasting color. Red bags or red containers may be used in lieu of
labels.
b. Equipment contaminated with blood or OPIM must be examined
prior to servicing or shipping, and decontaminated as necessary.
Portions of the equipment not feasible for decontamination are to
be tagged with a BIOHAZARD label and the information
communicated verbally and/or in written form to service personnel.
3. Eating, drinking, smoking, applying cosmetics or lip balm, and handling
contact lenses in any area where there is reasonable likelihood of
occupational exposure is strictly prohibited. Storage of food and drink is
prohibited in refrigerators, freezers, shelves, cabinets or on countertops or
bench tops where blood or OPIM are present.
4. Mouth pipetting is strictly prohibited.
5. Splash, spills, contaminated broken glass, fluid/tissue manipulation - All
procedures involving blood or OPIM must be performed in such a manner
as to minimize splashing, spraying, spattering, and generation of droplets
of these substances. Broken glass that is contaminated is to be cleaned
up using mechanical means, i.e., dust pan and broom or brush.
6. In accordance with the Needlestick Safety and Prevention Act, single-use
needles with hinged or sliding sheaths and tube holders with needle
guards are used to prevent needle stick injury.
7. ONU identifies the need for changes in engineering controls and work
practices through its Biosafety committee activities and based on the
recommendation of the employees who may have new information
provided by a supplier, through specialized training, or following a review
of the literature and OSHA updates. Both employees and management
personnel are involved in the process while the ECP program coordinator
is responsible for ensuring that these recommendations are implemented.
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VI. Personal Protective Equipment (PPE)
Personal protective equipment is provided to employees by ONU at no cost to them
and, when used correctly by employees, will provide protection from exposure to
potentially infectious or contaminated materials by creating an impervious barrier.
Personal protective equipment includes, but is not limited to:
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Disposable latex or hypoallergenic gloves;
Laboratory coats or gowns;
Face shields;
Face masks;
Eye protection (e.g., goggles);
Pocket cardiopulmonary resuscitation (CPR) masks with a one-way valve.
PPE is located in work areas for easy access and supplies are available by contacting
the manager of the university warehouse.
A. All employees are to wear personal protective equipment when performing
procedures in which potential exposure to the skin, eyes, mouth, nose or broken
areas of the skin may reasonably be anticipated. Those wearing PPE must
observe the following procedures:
1. Wash hands immediately or as soon as feasible after removing gloves or other
PPE. Disposable gloves are not to be washed or decontaminated for reuse!
Replace disposable gloves as soon as practical after contamination, or if they
are torn, punctured or otherwise lose their ability to function as a protective
barrier.
2. Remove and appropriately discard PPE after it becomes contaminated and
before leaving the work area.
3. Remove immediately any garment contaminated by blood or OPIM in a manner
to avoid contact with the outer surface.
4. Place used/and or contaminated disposable PPE in appropriately labeled
biohazard waste containers. Non-disposable but contaminated PPE is
decontaminated before reuse or prior to storage.
a. Utility gloves may be decontaminated for reuse if their integrity is not
compromised; these gloves are to be discarded if they show signs of
tearing, puncturing, cracking, peeling, or deterioration.
b. Decontaminate face shields, reusable eye protection, and resuscitation
equipment by soaking for no less than 10 minutes in a freshly-prepared
solution of household bleach mixed with water in a 1:10 solution (1/4
cup bleach in 1 gallon water). Rinse well with clean water and dry
thoroughly before reuse and/ or placement in storage.
5. 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.
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VII.
Housekeeping
Regulated waste is placed in containers which are closable, constructed to contain all
contents and prevent leakage, appropriately labeled or color-coded (see the following
section “Labels”), and closed prior to removal to prevent spillage or protrusion of
contents during handling.
A. Contaminated sharps are discarded immediately or as soon as possible in
containers that are closable, puncture-resistant, leak proof on sides and bottoms,
and appropriately labeled or color-coded. Sharps disposal containers are
available in work areas and classrooms, readily accessible to prevent exposure
to blood borne pathogens. Broken glassware that may be contaminated is only
picked up using mechanical means, such as a brush and dustpan.
B. The amount of regulated waste generated at ONU is expected to vary.
C. Regulated waste is disposed of in the following manner:
1. Collect all regulated waste in a closing, leak-proof, Red Bag.
2. Dispose of all regulated waste in the Biohazard Waste Container, in
accordance with applicable Federal, State and local regulations.
3. If the bag is contaminated with blood or OPIM double-bag it prior to
handling, storing and or transporting the bag.
4. Place disposable syringes, needles, blades, broken glass and other sharp
items in the puncture-resistant Sharps Container for disposal. Employees
WILL NOT pick up sharp objects directly with their hands. Reusable
containers will not be opened, emptied or cleaned manually or in any other
manner which will expose employees to the risk of percutaneous injury.
Employees WILL NOT reach by hand into a container of reusable
contaminated sharp objects.
5. Sealed containers of regulated biohazard waste are picked-up by
housekeeping and delivered to the ONU warehouse. For pick-up, call the
physical plant. The waste is stored at the warehouse until pick-up and
disposal.
D. Laundry - Personnel will wear disposable lab coats or aprons, gloves and other
applicable PPE when responding to an accident or when performing routine
cleaning of guest rooms where blood or OPIM are present. Laundering of
contaminated articles will be performed following these requirements:
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Contaminated laundry will be handled as little as possible, with minimal
agitation.
Wet contaminated laundry is placed in a leak-proof, labeled or colorcoded container for transport.
Laundering will be performed by: Weekdays 8 – 5:30 p.m., contact
physical plant for more information. After hours, and on holidays, contact
Security at 2222 or the University operator (dial ‘0’) to arrange for
contact with the supervisor on call.
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VIII.
Labels and Signage
A. Any device or bag that contains a potential biological hazard will be marked with
the following:
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Warning labels stating Biohazard
Biohazard Symbol
B. Warning labels will be firmly attached to containers of regulated waste,
refrigerators and freezers containing blood or other potentially infectious material,
and any other containers used to store, transport or ship blood or other potentially
infectious material.
C. Employees are responsible for ensuring that warning labels are affixed or that red
bags are used as required if regulated waste or contaminated equipment is
brought into the facility. Employees are to notify housekeeping/physical plant if
they discover regulated waste containers, refrigerators containing blood or OPIM,
contaminated equipment, etc., without proper labels.
IX. Hepatitis B Vaccination
Employees whose jobs may reasonably be anticipated to involve direct contact with blood
or OPIM will be offered the Hepatitis B vaccination series after initial employee training and
within 10 days of initial assignment to all employees identified in the exposure
determination section of this plan. Vaccination is encouraged unless: 1) documentation
exists that the employee has previously received the series; 2) antibody testing reveals that
the employee is immune; or 3) medical evaluation shows that vaccination is
contraindicated.
A. Employees are strongly urged to follow the vaccination series through to completion
as recommended in the U.S. Public Health guidelines on HBV prophylaxis.
B. If an eligible employee chooses not to receive the Hepatitis B vaccination, the
employee must sign a Hepatitis B Declination Statement which is filed in the Office of
Human Resources. Employees who decline may request and obtain the vaccination at
a later date at no cost.
C. Vaccination will be given according to standard medical practice under the supervision
of a licensed physician or another licensed healthcare professional.
1. Following a medication evaluation by a licensed physician or other qualified
healthcare provider, a written copy of the evaluation will be obtained and
provided to the employee within 15 days of completion of the evaluation. It will
be limited to whether the employee requires the hepatitis vaccine and whether
the vaccine was administered.
2. If a routine booster dose of Hepatitis B vaccine is recommended by the U. S.
Public Health Service at a future date, the booster dose will be made available at
no cost to eligible employees by ONU.
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D. All laboratory tests will be conducted by an accredited laboratory at no cost to the
employee.
E. The ECP coordinator will provide training to employees on hepatitis B vaccinations,
addressing safety, benefits, efficacy, methods of administration, and availability.
X. Post-Exposure Incident Evaluation and Follow-up
The ECP program coordinator is the person responsible for reviewing and documenting in
the exposure injury log the circumstances of all exposure incidents to determine:
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Engineering controls in use at the time
Work practices followed
A description of the device being used (including type and brand)
Protective equipment or clothing that was used at the time of the exposure
Location of the incident
Procedure performed when the incident occurred
Employee’s training
Following an exposure incident, employees have the opportunity to receive at no cost, at a
reasonable time and place, a confidential medical evaluation performed by or under the
direct supervision of a licensed physician. All associated testing will be performed by an
accredited laboratory. Students and others should contact their own health practitioner
because:
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He or she may need to be tested for Hepatitis B and HIV in the manner recommended
by the CDC as soon as possible after the incident, including the opportunity for repeat
testing at six weeks, twelve weeks, and six months post exposure.
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He or she may need to receive post exposure gamma-globulin, Hepatitis B immunoglobulin, and/or Hepatitis B Vaccination series or booster when medically indicated.
A. In the event of an occupational exposure, employees are to, following initial first
aid (e.g., clean the wound, flush eyes or other mucous membrane, etc.),
immediately contact their supervisor, then the ECP program coordinator or his/her
designee, and within twenty-four hours of the incident, contact the Human
Resources office. A student is to notify the faculty of record who will report the
incident to the ECP coordinator.
B. An Exposure incident form, available from the employee’s department/unit main
office or the human resources office, with directions for completion will be provided
to the employee or student at the time of exposure. The route of exposure, the
status of the source (unless the employer can establish that identification is
infeasible or prohibited by state or local law), and the circumstances of the
exposure will be documented on the form. The completed form and associated
records will be sent to the ECP program coordinator for review before being
forwarded to the Human Resources Office. An attempt will be made to contact the
source patient to collect and test their blood for the presence of Hepatitis B and
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16
HIV (not needed if the source individual is already known to be HIV, HCV, and/or
HBV positive). Additionally, the exposed employee will be offered the opportunity
to:




Complete a confidential medical history at a local health facility;
To be tested for Hepatitis B and HIV in the manner recommended by CDC as
soon as possible after the incident, including the opportunity for repeat testing
at 6 weeks, 12 weeks and 6 months post exposure; and
To receive post-exposure gamma globulin or Hepatitis B immune globulin
and/or the Hepatitis B vaccination series or booster, when medically indicated,
at ONU’s expense.
If an employee does not give consent for HIV serological testing during
collection of blood for baseline testing, the sample is to be held for 90 days; if
the employee elects to have the baseline sample tested during this waiting
period, the testing is to be performed as soon as feasible.
C. Follow-up care of the exposed worker will include counseling, medical evaluation
of any acute febrile illness that occurs within 12 weeks post exposure, and the use
of safe and effective post exposure measures according to standard medical
practice.
D. The treating health care facility will send the Human Resources Director a
statement that:


the employee has been informed in writing of the results of the evaluation
the employee has been informed in writing of any medical conditions subsequent
to exposure to blood or other potentially infectious materials that require further
evaluation or treatment.
E. All other health findings are to remain confidential and not included in the
healthcare facility’s written report to the employer.
F. The ECP program coordinator is to:


Provide the healthcare professional(s) responsible for the employee’s
hepatitis B vaccination and post-exposure evaluation and follow-up a copy
of OSHA’s bloodborne pathogen standard.
Ensure that the health care professional evaluating an employee after an
exposure incident receives a description of the employee’s duties relevant
to the incident, route(s) of exposure, circumstances of exposure, if
possible a copy of the source individual’s blood tests, other relevant
information on the health and vaccination status of the employee
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17
XI. Recordkeeping
For Employees, the Office of Human Resources is responsible for keeping all records
pertaining to the ECP. Additionally the University biosafety committee chair must have
access to all training records for staff, faculty, volunteers, and students. Training records
for OSHA BBP and bioafety must also be kept on site. (In labs etc.) For students, it’s the
Department Office of record. These records include:




Name of employee/ or student
Employee/Student ID number
The Employee’s/Student’s Hepatitis B vaccination status
Copies of the results of examinations, medical testing and follow-up procedures that
took place as a result of the occupational exposure.
A. Document Retention - the Office of Human Resources will document any exposure
incident in accordance with the Access to Employee Exposure and Medical
Records as found in the Code of Federal Regulations 1910.20. Records will be
maintained in confidence by the Office of Human Resources for at least the
duration of employment plus 30 years.
B.Sharps Injury Log - will be maintained to record all percutaneous injuries from
contaminated sharps. The information will be recorded in such a way as to protect
the confidentiality of the injured employee. The log will contain: (a) the type and
brand of device involved in the incident; (b) the Department or work area where the
exposure incident occurred; and (c) an explanation of how the incident occurred.
C. Exposure Record - all records are kept confidentially as part of the employee's
records, and no information will be disclosed or reported without the employee's
written consent, except as may be required by law. Any exposure incident will be
documented on the exposure incident form maintained in the employee's
confidential file kept by the Office of Human Resource.
D. Training Records - while generated by the ECP coordinator, the records will be
maintained by the Office of Human Resources for three (3) years from the date of
training, including the date of training, contents or summary of training topics,
names and qualifications of persons conducting the training, and the names and
job titles of all employees attending the training.
EXCEPTION – student training records will be maintained by the department of record, but
made available upon request from the Human Resources Office and/ or the ECP
coordinator.
XII.
Employee and Student ECP Education
A well-informed, properly trained employee is crucial to the successful implementation and
effectiveness of ONU’s ECP activities. Education of employees regarding the ECP is
accomplished by means of initial training and repeated annually, and upon employment for
new employees. Additionally, training will be provided to students who, though not
expected to respond to situations involving potential exposure, may be at risk for exposure
due to their studies and campus activities.
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18
A. Presentation - training that is tailored to the educational level and language of
employee or student will include an opportunity to ask questions and have them
answered by a knowledgeable trainer. The ONU Office of Human Resources and
the ECP program coordinator are responsible for scheduling and documenting the
training.
B. Topics covered during training will include, but not be limited to:












Explanation and location of the Exposure Control Plan and the Bloodborne
Pathogens Standard as found in the Code of Federal Regulations 1910.1030;
The epidemiology, modes of transmission and symptoms of diseases
transmitted via the human blood;
Procedures and job tasks that may expose employees to blood and/ or OPIM;
Engineering and work practice controls used at ONU;
Limitations and basis for selection of personal protective equipment, including
the types
available, proper use, location within the facility, removal, handling,
decontamination and disposal;
Visual warnings of biohazards, including labels, signs and color-coded Red
containers;
Information on the Hepatitis B program, including the benefits and safety of
vaccination, a test of protective titer, and that the vaccine will be offered free
of charge;
Information on procedures to use in an emergency that may involve an
exposure incident;
Explanation of post-exposure evaluation and follow-up procedures;
How to inspect equipment for contamination; and
How to decontaminate equipment.
C. Education Methods - ONU will utilize appropriate training methods that achieve
these objectives: (a) encourage trainee involvement with the topic; (b) utilize
appropriate audiovisual aids; (c) build upon the participants’ current knowledge
base of the subject; (d) allow opportunity for interactive questions and answers
with the person conducting the training session; (e) offer handouts or other
methods to obtain further information.
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19
Authorized Signatures
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20
ADDENDUM







Hepatitis Declination Form
Exposure Incident Form
The exposed individual must complete and submit this form to the ECP coordinator
within 24 hours following an occupational exposure to human blood.
Sharps Injury Log
Source Individual’s Consent or Refusal for Infectivity Testing Form
The individual whose blood was involved in the occupational exposure (not the
exposed individual) must complete and sign this form before submitting to testing.
Refusal of Post-Exposure Medical Evaluation Form
The exposed individual must complete this form only if refusing post-exposure
medical evaluation by a health care professional.
OSHA Standard 1910.1030 (on-line at
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS
&p_id=10051
Summary of Key Provisions OSHA Standard 1910.1030
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21
Ohio Northern University
HEPATITIS VACCINATION DECLINATION FORM
Hepatitis B Vaccination Declination Statement
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 infection. I have been given the
opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself. However, I
decline this vaccine. I understand that 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 myself.
____________________________________________
Employee Name (PRINT)
Date ___________________
____________________________________________
Employee Signature
ID No. __________________
Reason for Declination (please check one):
At this time, I do not choose to receive the Hepatitis B vaccine.
I have previously completed the 3 dose series of the Hepatitis B vaccine.
Documentation of this is attached.
I have been exposed to Hepatitis B and blood tests reveal that I have developed
antibodies. Documentation of this fact is attached.
Other (please briefly explain:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Filed to employee’s record
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_____________________________________________
Date
22
Ohio Northern University
Sharps Injury Log
Year______
Date
Case/Report
No.
Type of
Device (e.g.
syringe,
suture
needle)
Brand
Name of
Device
Work Area
where
injury
occurred
(e.g.
geriatrics
lab)
Brief description of how incident occurred
(i.e. procedure being done, action being
performed)
29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h)(5), requires an employer to establish and maintain a Sharps Injury
Log for recording all percutaneous injuries in a facility occurring from contaminated sharps. The purpose of the Log is to aid in the evaluation of
devices being used in healthcare and other facilities and to identify problem devices or procedures requiring additional attention or review. This
log must be kept in addition to the injury and illness log required by 29 CFR 1904. The Sharps Injury Log should include all sharps injuries
occurring in a calendar year. The log must be retained for five years following the end of the year to which it relates. The Log must be kept in a
manner that preserves the confidentiality of the affected employee.
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23
Ohio Northern University
Exposure Incident Report
(Routes, Circumstances, & Follow-up of Exposure Incident)
Date Completed
________________________________________________________
Name ______________________________________ SSN/ID Number _______________
Home Phone
Birth Date
___________________________ Work Phone __________________
________________________ Job Title ______________________________
Vaccination Status
 YES
Current with HEP B:
EXPLANATIONS:
 NO
 UNKNOWN
________________________________________________________
________________________________________________________________________
Date of Exposure __________ Time of Exposure __________
_____a.m.
_____ p.m.
Location of Exposure (be very specific): ________________________________________
________________________________________________________________________
Nature of Exposure (e.g., work-related trauma, school-related activity, etc. – be very
specific)
________________________________________________________________________
________________________________________________________________________
Describe what task(s) you were performing when the exposure occurred (be very specific):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Were you wearing PPE when the exposure occurred?  YES
Did the PPE fail?  YES  NO
 NO
If yes, please explain. ______________________
________________________________________________________________________
________________________________________________________________________
What fluids or OPIM were you exposed to? ______________________________________
What type of exposure? (check all that apply)
 Mucous membranes (e.g., eyes, nose, mouth)
 Skin puncture, tissue wound
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 Spill on Clothing and/ or Intact Skin
 Other (explain) _______________________________
24
Ohio Northern University Exposure Incident Report
Page 2
Did you receive medical attention?
 YES
 NO
If yes, where? _____________________________________________________________
When? __________________________________________________________________
By whom? _______________________________________________________________
ID Source individual (what or who was the source of blood/fluid exposure) _____________
________________________________________________________________________
________________________________________________________________________
Please provide any additional information regarding this exposure incident.
Blood Testing Offered?
 NO
 YES
Explain ______________________
________________________________________________________________________
________________________________________________________________________
Vaccination Offered/Recommended?
 NO
 YES
Explain ____________
________________________________________________________________________
________________________________________________________________________
Counseling Offered?
 NO
 YES
Explain ______________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Injured Person advised of need for further evaluation and medical attention?
 NO
 YES
Explain ____________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________
__________________
Injured Person Signature
Date
Reviewed by: _____________________________________________________________
Filed: ___________________________________________________________________
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25
Ohio Northern University
Source Individual’s Consent or Refusal Form Infectivity Testing
*This person’s blood or body fluids provided the source of this exposure.
NOTE: Print this form and distribute copies of this form to: □ Health Care Professional □ ONU Human Resources,
BioSafety Committee
Exposed Individual's Information
Name (Please Print):_____________________________________________
Department or Program:__________________________________________
Telephone Number: ______________Exposure Date:___________________
Source Individual's Statement of Understanding
I understand that employers are required by law to attempt to obtain consent for HIV, HBV,
and HCV infectivity testing each time an employee is exposed to the blood or bodily fluids
of any individual. I understand that an ONU employee or student intern has been
accidentally exposed to my blood or bodily fluids and that testing for HIV, HBV, and HCV
infectivity is requested. I am not required to give my consent, but if I do, my blood will be
tested for these viruses at no expense to me.
I have been informed that the test to detect whether or not I have HIV antibodies is not
completely reliable. This test can produce a false positive result when an HIV antibody is
not present and that follow-up tests may be required.
I understand that the results of these tests will be kept confidential and will only be released
to medical personnel directly responsible for my care and treatment, to the exposed
healthcare worker for his or her medical benefit only and to others only as required by law.
Consent or Refusal & Signature
I hereby consent to:
□ HIV Testing
□ HBV Testing
□ HCV Testing
I hereby refuse consent to:
□ HIV Testing
□ HBV Testing
□ HCV Testing
Source Individual Identification
Source individual's printed name and signature:____________________________
Date Signed:___________________________
Relationship (If signed by someone other than the source Individual):
________________________________
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Ohio Northern University
Refusal of Post-Exposure Medical Evaluation Form for Bloodborne Pathogen Exposure
Supervisor or Clinical Instructor: Complete this form only if the exposed individual refuses postexposure medical evaluation by a health care professional. Send this completed form to ONU
Human Resources, Biosafety Committee Chair
Exposed Individual Information
Name:_____________________________________________________________
Department or Program:_______________________________________________
Exposure Date: ________________ Social Security Number:__________________
Exposure Information
Facility & Department where the incident occurred:___________________________
Type of protection equipment used (gloves, eye protection, etc.):________________
Describe how you were exposed:________________________________________
__________________________________________________________________
Tell how this type of exposure can be prevented:____________________________
__________________________________________________________________
Statement of Understanding
I have been fully trained in ONU's Exposure Control Plan, and I understand I may have
contracted an infectious disease such as HIV, HCV or HBV. I also understand the
implications of contracting these diseases. I have been offered follow-up medical testing
free of charge by my employer to determine whether or not I have contracted an infectious
Disease such as HIV, HCV, or HBV. I have also been offered follow-up medical care in the
form of counseling and medical evaluation of any acute febrile illness (new illness
accompanied by fever) that occurs within twelve weeks post-exposure.
Despite all the information I have received, for personal reasons, I freely decline this postexposure evaluation and follow-up care.
Exposed Individual’s Signature:_________________________ Date: ______________
Witness Name (Please Print):____________________________________________
Witness Signature: ________________________ Witness Date: __________________
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KEY PROVISIONS OF OSHA BLOODBORNE PATHOGEN STANDARD
U.S. Department of Labor
Program Highlight
Fact Sheet No. OSHA 92-46
PURPOSE: Limits occupational exposure to blood and other potentially infectious materials
since any exposure could result in transmission of bloodborne pathogens which could lead
to disease or death.
SCOPE: Covers all employees who could be "reasonably anticipated" as the result of
performing their job duties to face contact with blood and other potentially infectious
materials. OSHA has not attempted to list all occupations where exposures could occur.
"Good Samaritan" acts such as assisting a co-worker with a nosebleed would not be
considered occupational exposure.
Infectious materials include semen, vaginal secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any
body fluid visibly contaminated with blood and all body fluids in situations where it is difficult
or impossible to differentiate between body fluids. They also include any unfixed tissue or
organ other than intact skin from a human (living or dead), human immunodeficiency virus
(HIV)- containing cell or tissue cultures, organ cultures and HIV or hepatitis B (HBV)containing culture medium or other solutions as well as blood, organs or other tissues from
experimental animals infected with HIV or HBV.
EXPOSURE CONTROL PLAN: Requires employers to identify, in writing, tasks and
procedures as well as job classifications where occupational exposure to blood occurs-without regard to personal protective clothing and equipment. It must also set forth the
schedule for implementing other provisions of the standard and specify the procedure for
evaluating circumstances surrounding exposure incidents. The plan must be accessible to
employees and available to OSHA. Employers must review and update it at least annually-more often if necessary to accommodate workplace changes.
METHODS OF COMPLIANCE: Mandates universal precautions, (treating body
fluids/materials as if infectious) emphasizing engineering and work practice controls. The
standard stresses handwashing and requires employers to provide facilities and ensure
that employees use them following exposure to blood. It sets forth procedures to minimize
needlesticks, minimize splashing and spraying of blood, ensure appropriate packaging of
specimens and regulated wastes and decontaminate equipment or label it as contaminated
before shipping to servicing facilities.
Employers must provide, at no cost, and require employees to use appropriate personal
protective equipment such as gloves, gowns, masks, mouthpieces and resuscitation bags
and must clean, repair and replace these when necessary. Gloves are not necessarily
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28
required for routine phlebotomies in volunteer blood donation centers but must be made
available to employees who want them.
The standard requires a written schedule for cleaning, identifying the method of
decontamination to be used, in addition to cleaning following contact with blood or other
potentially infectious materials. It specifies methods for disposing of contaminated sharps
and sets forth standards for containers for these items and other regulated waste. Further,
the standard includes provisions for handling contaminated laundry to minimize exposures.
HIV AND HBV RESEARCH LABORATORIES AND PRODUCTION FACILITIES: Calls for
these facilities to follow standard microbiological practices and specifies additional
practices intended to minimize exposures of employees working with concentrated viruses
and reduce the risk of accidental exposure for other employees at the facility. These
facilities must include required containment equipment and an autoclave for
decontamination of regulated waste and must be constructed to limit risks and enable easy
clean up. Additional training and experience requirements apply to workers in these
facilities.
HEPATITIS B VACCINATION: Requires vaccinations to be made available to all
employees who have occupational exposure to blood within 10 working days of
assignment, at no cost, at a reasonable time and place, under the supervision of licensed
physician/licensed healthcare professional and according to the latest recommendations of
the U.S. Public Health Service (USPHS). Prescreening may not be required as a condition
of receiving the vaccine. Employees must sign a declination form if they choose not to be
vaccinated, but may later opt to receive the vaccine at no cost to the employee. Should
booster doses later be recommended by the USPHS, employees must be offered them.
POST-EXPOSURE EVALUATION AND FOLLOW-UP: Specifies procedures to be made
available to all employees who have had an exposure incident plus any laboratory tests
must be conducted by an accredited laboratory at no cost to the employee. Follow-up must
include a confidential medical evaluation documenting the circumstances of exposure,
identifying and testing the source individual if feasible, testing the exposed employee's
blood if he/she consents, post-exposure prophylaxis, counseling and evaluation of reported
illnesses. Healthcare professionals must be provided specified information to facilitate the
evaluation and their written opinion on the need for hepatitis B vaccination following the
exposure. Information such as the employee's ability to receive the hepatitis B vaccine
must be supplied to the employer. All diagnoses must remain confidential.
HAZARD COMMUNICATION: Requires warning labels including the orange or orange-red
biohazard symbol affixed to containers of regulated waste, refrigerators and freezers and
other containers which are used to store or transport blood or other potentially infectious
materials. Red bags or containers may be used instead of labeling. When a facility uses
universal precautions in its handling of all specimens, labeling is not required within the
facility. Likewise, when all laundry is handled with universal precautions, the laundry need
not be labelled. Blood which has been tested and found free of HIV or HBV and released
for clinical use, and regulated waste which has been decontaminated, need not be labeled.
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29
Signs must be used to identify restricted areas in HIV and HBV research laboratories and
production facilities.
INFORMATION AND TRAINING: Mandates training within 90 days of effective date,
initially upon assignment and annually - employees who have received appropriate training
within the past year need only receive additional training in items not previously covered.
Training must include making accessible a copy of the regulatory text of the standard and
explanation of its contents, general discussion on bloodborne diseases and their
transmission, exposure control plan, engineering and work practice controls, personal
protective equipment, hepatitis B vaccine, response to emergencies involving blood, how to
handle exposure incidents, the post-exposure evaluation and follow-up program,
signs/labels/color-coding. There must be opportunity for questions and answers, and the
trainer must be knowledgeable in the subject matter. Laboratory and production facility
workers must receive additional specialized initial training.
RECORDKEEPING: Calls for medical records to be kept for each employee with
occupational exposure for the duration of employment plus 30 years, must be confidential
and must include name and social security number; hepatitis B vaccination status
(including dates); results of any examinations, medical testing and follow-up procedures; a
copy of the healthcare professional's written opinion; and a copy of information provided to
the healthcare professional. Training records must be maintained for three years and must
include dates, contents of the training program or a summary, trainer's name and
qualifications, names and job titles of all persons attending the sessions. Medical records
must be made available to the subject employee, anyone with written consent of the
employee, OSHA and NIOSH--they are not available to the employer. Disposal of records
must be in accord with OSHA's standard covering access to records.
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