UC Davis Health System – Schools of Health
BLOODBORNE PATHOGEN EXPOSURE-CONTROL PLAN
Step one: Develop an exposure-control plan
Requirement source: The standard
All employers must establish a written exposure-control plan designed to eliminate or minimize
occupational exposures if their employees work with:
 Human body fluids including semen, vaginal secretions, cerebrospinal fluid, pleural fluid,
pericardial fluid, peritoneal fluid, amniotic fluid, saliva from dental procedures, any body
fluid visibly contaminated with blood such as saliva or vomit, and all body fluids in
situations such as emergency response calls where it is difficult or impossible to
differentiate between body fluids;
 Any unfixed tissue or organ other than intact skin from a living or dead human;
 HIV-containing cell or tissue cultures, organ cultures and HIV-, HBV- or HCV-containing
culture medium or other solutions; or
 Blood, organs or other tissues from experimental animals infected with HIV, HBV or HCV.
.
The exposure-control plan must contain at least the following elements:
 Exposure determination;
 Schedule and method of compliance;
 Hepatitis B vaccinations and post-exposure evaluation and follow-up;
 Communication of hazards to employees; and
 Record keeping.
Title 8, Section 5193 California Code of Regulation (CCR)
Implementation
The exposure-control plan must be a written document for each location and must address the minimum
elements of the standard. The plan must be accessible to employees. It must be updated at least annually
and whenever necessary to reflect new or modified tasks and procedures that affect occupational
exposure to reflect new or revised employee positions with occupational exposure and to review the
exposure incidents that occurred since the previous update. Compliance with this requirement can be
accomplished by use of model forms. A model title page and introduction section can be found in
Appendix I.
Fill in the blanks on the title page. List the name of the department, the room number and building name of
the work location. The Principal Investigator (PI) or laboratory supervisor should be listed as the
responsible individual. List the work phone number in case of emergency. The most recent date of review
should also be listed.
Implementation Date: JANUARY
Annual Review Date:
Annual Review Date:
Annual Review Date:
Annual Review Date:
__________
__________
__________
__________
Appendix I: Exposure-control plan title page
Completion of this form indicates that it is the policy of the employer to fully comply with CCR Title 8, Section 5193.
A.
Department information
Department name:
Building:
B.
C.
Schools of Health – Education & Research
Room:
Person with authority and responsibility for the BloodBorne Pathogen [exposure-control] Plan
Principal Investigator/supervisor:
Lab Contact:
Phone:
Phone:
The person completing this plan is:
Name:
Role/Title:
Lab Contact
Phone:
Exposure-control plan introduction
This plan is designed to help you identify, minimize and/or eliminate risk from exposure to potentially
infectious materials to which you may be exposed during your employment. The plan is effective
immediately.
Certain diseases can be transmitted from an infected individual or research animal to a person by contact
with blood or other body fluids. These diseases include, but are not limited to, hepatitis B virus (HBV),
human immunodeficiency virus (HIV) and hepatitis C virus (HCV).
To protect yourself you are required to:
 Learn what tasks may result in exposure;
 Follow the work routines established by this plan;
 Report any incidents involving exposure;
 Report any violations of the requirements of this plan; and
 Assist your co-workers in understanding and complying with this plan’s requirements.
Following these steps will help you minimize risk from “occupational exposure.” Occupational exposure
means reasonably anticipated contact between your skin, eye or mucous membranes; piercing of skin; or
membrane contact with blood, body fluids or other potentially infectious materials that may occur in the
performance of your duties. Occupational exposure from blood includes all forms of human blood, whether
it is liquid, semi-liquid or dried and caked. You must report all occupational exposures to your supervisor.
“Standard Precautions” is an approach to infection control. According to the concept of Standard
Precautions, all human blood and certain human body fluids are treated as if known to be infectious for
HIV, HBV, HCV and other bloodborne pathogens.
All occupational illnesses or injuries must be reported regardless of severity. You need not report catching
a cold, flu or other virus, since that may occur anywhere. On the other hand, you must report any illness
resulting from an exposure addressed in the exposure-control plan.
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Step two: Identify job titles and potentially infectious materials
associated with the employed occupations
Requirement source: The standard
Each employer who has an employee(s) with occupational exposure ... shall prepare an exposure
determination. This exposure determination shall include the following:
 A list of all job classifications ... that have occupational exposure; and
 A list of tasks and procedures or groups of closely related tasks and procedures in which
occupational exposure occurs and that are performed by employees in job classifications listed ...
Title 8, CCR Section 5193
Implementation
Determine which job titles could involve occupational exposure and list them in the Exposure
Determination section in Appendix II. Be sure to review job descriptions and discuss with each employee
the regular and occasional duties that could bring them into contact with blood, body fluids, equipment,
laundry, work surfaces or other materials that might become contaminated with blood or body fluids.
Tasks and Procedures
List all tasks and procedures that could involve occupational exposure. Closely related tasks may be
grouped under a generic listing (e.g., performance of all laboratory tests). Be certain to include duties such
as cleaning clinical areas or equipment, disposing of medical waste or soiled laundry, and handling
Personal Protective Equipment (PPE).
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Appendix II: Exposure determination
A. The following job titles have been identified as positions that have a degree of occupational
exposure:
All personnel that conduct laboratory work in this PI’s lab
OR
Title:
Title:
Title:
Title:
Title:
Title:
B.
Other Potentially Infected Material (OPIM) includes the following human body fluids:
 Saliva in dental procedures;
 Semen;
 Vaginal secretions;
 Cerebrospinal fluid (fluid from the head or spine);
 Synovial fluid (fluid from a joint);
 Pleural fluid (fluid from the lung sac);
 Pericardial fluid (fluid from the heart);
 Peritoneal fluid (fluid from the abdomen);
 Amniotic fluid (fluid from a pregnant uterus);
 Any body fluid that is visibly contaminated with blood, such as saliva or vomit;
 All body fluids in situations where it is difficult or impossible to differentiate between body fluids;
 Any unfixed tissue or organ, other than intact skin, from a living or dead human;
 Cells or tissue cultures, organ cultures, culture media or other solutions containing known or
suspected HIV, HBV or HCV; and
 Blood, organs or other tissues from experimental animals infected with HIV, HBV or HCV.
C.
The following tasks and procedures involve potential occupational exposure. Employees
performing these tasks and procedures are at risk for occupational exposure:
Task or procedure:
Task or procedure:
Task or procedure:
Task or procedure:
Task or procedure:
Bacterial Culture
Cell Line Culture
Injection of Human Cell Lines into Animal Hosts
Animal Handling
Preparation of Viral Particles
Expand this list as needed with supplemental pages.
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Step three: Identify compliance methods
Requirement source: The standard
Universal precautions shall be observed to prevent contact with blood or other potentially infectious
materials. Under circumstances in which differentiation between body fluid types is difficult or impossible,
all body fluids shall be considered potentially infectious materials. Engineering and work practice controls
shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after
institution of these controls, personal protective equipment shall also be used.
Title 8, CCR Section 5193 California Code of Regulation
Implementation
The department or laboratory must establish procedures and methods for preventing contact with human blood or
Other Potentially Infectious Material (OPIM).
Handwashing facilities or antiseptic towelettes will be provided in an area readily accessible to all employees who
potentially could be exposed to bloodborne pathogens. When using antiseptic towelettes, hands should be washed
with soap and running water as soon as feasible. Employees should also wash their hands immediately after
removing gloves or other Personal Protective Equipment (PPE).
Fill in the location of all handwashing sinks and indicate storage locations for antiseptic towelettes on Appendix III.
Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses are prohibited in work
areas where occupational exposure to bloodborne pathogens may occur. Food and drink should not be kept in
refrigerators, freezers, shelves, cabinets, countertops or benchtops where potentially infectious materials are
present. Indicate in Section C of Appendix III the areas where such activities are prohibited.
Equipment that has been contaminated should be examined and decontaminated prior to servicing or shipping.
If decontamination is not feasible, the equipment should be labeled as to the nature of contamination. The person
responsible for the equipment should be listed under Part E of Appendix III.
PPE must be provided to employees at no cost. Protective equipment includes, but is not limited to, gloves, gowns,
laboratory coats, face shields or masks, eye protection, mouthpieces, resuscitation bags and pocket masks or
other ventilation devices. PPE should provide a barrier to potentially infectious materials. The employer is
responsible for ensuring that employees wear the protective equipment. Indicate under Section 3a of Appendix III
the party responsible for laundry in your facility. No PPE should be worn when leaving the work area.
Place a check in the box beside each item of protective equipment provided at the facility under Section 3a of
Appendix III. Indicate each procedure to be performed at your facility in Section 3f Appendix III, and place an “x”
in each appropriate column to indicate which type of protection is required.
Housekeeping Requirements: Cal-OSHA regulations require you to establish “an appropriate written schedule”
for cleaning and a method of decontamination suitable to the area, surface type, soil type and tasks performed.
Complete the housekeeping section in Section 4 of Appendix III based upon your determinations. Add additional
pages to the chart if needed, and include any additional appropriate housekeeping responsibilities. Be sure to
modify job descriptions to reflect which individuals are responsible for housekeeping functions.
Regulated Waste: Contaminated materials should be disposed of as soon as possible. Waste should be placed in
containers that are closable, puncture resistant, leak proof and labeled. Indicate the location of contaminated
sharps containers under Section 5 of Appendix III.
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Appendix III: Methods of compliance
A.
Standard precautions
“Standard precautions” is an approach to infection control. According to the standard precautions concept,
all human blood and other body fluids as well as unfixed tissues and organs other than skin are treated as
if known to be infectious for HIV, HBV, HCV and other bloodborne pathogens. It is recognized that the
most effective mechanism for preventing infections with bloodborne pathogens is to minimize occupational
exposure by minimizing potential contact with contaminated materials. As mandated by the Bloodborne
Pathogen Standard, standard precautions will be followed at all times at UC Davis to prevent contact with
blood or Other Potentially Infectious Material (OPIM).
B.
Work practice controls
Work practices appropriate to protect employees from potentially infectious materials have been
developed. You are required at all times to comply with these practices. In the event you do not or cannot
comply with any of these requirements, you must report the incident and circumstances to your PI or
supervisor for investigation and documentation.
1.
Handwashing
You must wash your hands immediately after removing gloves or other Personal Protective
Equipment (PPE). You must wash your hands and any other exposed skin with soap and water or
flush mucous membranes with water immediately following contact with blood or OPIM.
Handwashing facilities (sinks) are located in each lavatory and at these other locations (rooms)
and at alternating benches in:
If handwashing facilities are not readily accessible to you use antiseptic towelettes instead. These
towelettes are located: Not Applicable
If towelettes are used, you must still wash with soap and running water as soon as feasible
thereafter.
2.
Disposable needles and other sharp instruments
Contaminated needles and other contaminated sharp instruments must not be bent, recapped or
removed unless:
 There is no feasible alternative to doing so (e.g., as a result of a specific procedure); or
 Recapping or needle removal can be accomplished by use of a mechanical device or onehanded technique.
3.
Reusable sharp instruments (e.g., lancets, scalpels, etc.)
Immediately, or as soon as possible after use, contaminated reusable sharp instruments must be
placed in appropriate containers until proper disposal. These containers must be:
 Puncture resistant;
 Labeled “biohazard” and color-coded red;
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

4.
Leak-proof on the sides and bottom; and
Designed so that you need not reach by hand into the containers where such sharp
instruments have been placed.
Employee personal actions
Eating, drinking, smoking, applying cosmetics/lipstick/lip balm and handling contact lenses are
prohibited in laboratory work areas.
All procedures involving blood and OPIM must be performed to minimize splashing, spraying,
spattering and generation of droplets of these substances.
Mouth pipetting or suctioning of any material is prohibited.
5.
Handling Specimens
Specimens of blood or OPIM must be placed in a container that prevents leakage during
collection, handling, processing, storage, transport or shipping. Containers for storage, transport or
shipping are red and labeled “biohazard.” These containers must be closed and sealed prior to
being stored, transported or shipped.
If the outside of the primary container becomes contaminated or leaks, place it in a second
container for handling, processing, storage, transport or shipping. The secondary container should
be the same color as the primary container. Do not move contents from one container to another.
Similarly, if the specimen could puncture the primary container, place it in a leak-proof, punctureresistant secondary container.
C.
Personal protective equipment
1.
General
The following PPE is provided (check all that apply):
Gloves, disposable
Gloves, cryogenic
Laboratory coats
Gowns, disposable
Booties, disposable
Goggles
Face shield(s)
Surgical masks (for splash protection)
Respirator, Elastomeric, personally assigned,
must be fit tested by EH&S
Respirator, N95, Personally assigned, must
be fit tested by EH&S
List other(s) as needed:
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Your PI/supervisor has determined which PPE is needed for various tasks. It is your responsibility
to use them at all times. The PI/supervisor will consider any other PPE if it is deemed appropriate.
You must use the PPE for procedures as described in the protocols and BUA. If for some reason
you can not use the required protective equipment, you must discuss this with your supervisor
prior to performing the task.
PPE
Goggles
cleaned by
each individual.
Lab coats
laundered by
University Vendor
Gloves, disposable
disposed as MW by
each individual.
You must immediately let PI/supervisor know if any PPE needs to be repaired or replaced.
If a garment is penetrated by blood or OPIM, remove the garment immediately, bag it and dispose
of it in accordance with the policy for “Regulated Waste” (Section G, this step).
Remove all PPE prior to leaving the work area. Place this equipment in an appropriate designated
area or container for storage, washing, decontamination or disposal.
2.
Gloves
Gloves must be worn when you anticipate contact with blood or OPIM or if you anticipate handling
or touching potentially contaminated items or surfaces.
Disposable gloves (such as nonlatex surgical or examination gloves) must be replaced as soon as
practical when contaminated. If gloves are torn or punctured or if their ability to function as a
barrier is compromised, replace them immediately. Disposable gloves may not be washed or
decontaminated for re-use. Contaminated disposable gloves should be discarded in accordance
with the guidelines on regulated wastes.
Heavy rubber, leather or other general-purpose utility gloves may be decontaminated (washed or
autoclaved) for re-use if the integrity of the glove has not been compromised. However, they must
be discarded if they are cracked, peeling, torn, punctured or show other signs of deterioration or
when their ability to function as a barrier is compromised.
Under all circumstances, if you have cuts, scratches or other breaks in your skin, gloves are a
required precaution when even remote chances of exposure exist.
All appropriate PPE will be provided in correct sizes in a readily accessible area at the work site.
This includes hypoallergenic gloves, glove liners, powderless gloves or similar alternatives for
those who are allergic to normally provided gloves.
3.
Masks, Eye Protection and Face Shields
To protect against eye, nose or mouth contamination, wear either masks and eye protection
devices (such as goggles or glasses with solid side shields) or chin-length face shields whenever
splashes, spray, spatter or droplets of blood or OPIM may be generated.
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4.
Gowns, Aprons and Other Protective Body Clothing
Appropriate protective clothing such as, but not limited to, disposable gowns and aprons or lab
coats, clinic jackets or similar outer garments must be worn when it may be reasonably expected
that splashes, spray, spatter or droplets of blood or OPIM may be generated.
5.
Surgical Caps, Hoods and Boots
Surgical caps or hoods and/or shoe covers or boots must be worn when gross contamination can
reasonably be anticipated.
6.
Standard PPE Requirements
The PI/supervisor has established a binder with written protocols/procedures. The PPE
requirements are stated in the protocol and requirements for BUA work is stated in the BUA.
D.
Housekeeping
You are responsible for keeping your immediate work area clean and sanitary. If you become aware of
needs beyond general housekeeping, report your concern to your PI/supervisor.
All equipment and working surfaces must be cleaned and decontaminated using sanitizing cleanser after
contact with blood or OPIM.
Contaminated work surfaces must be decontaminated with disinfectant after completion of each procedure:
 Immediately when surfaces are overtly contaminated or after any spill of blood or OPIM; and
 At the end of the work day if the surface may have become contaminated since the last cleaning.
Disposable protective coverings, such as plastic wrap or aluminum foil used to cover equipment and work
area surfaces must be removed and replaced as soon as feasible after they become contaminated or at
the end of the work day if they may have become contaminated during the day.
All buckets, pails, cans, bins, baskets and similar receptacles intended for re-use that have a reasonable
likelihood of becoming contaminated with blood or OPIM must be inspected and decontaminated regularly
and as soon as possible after known or visible contamination.
Broken glass must not be picked up directly with the hands even if gloved. Rather, glass must be collected
by using broom and dust pan, tongs and forceps and then must be sanitized, disinfected or autoclaved.
The following schedule for cleaning and sanitizing or decontaminating must be observed:
Frequency
Immediately
After use
Monthly
Item to be cleaned
Spills, splashes, drips
Work surface
MW container
Method
10% bleach
10% bleach, 70% alcohol
10% bleach
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Person’s name
Each individual
Each individual
Lab contact
E.
Regulated Waste
Regulated waste is liquid or semi-liquid blood or OPIM; contaminated items that would release blood or
OPIM in a liquid or semi-liquid state if compressed; items caked with dried blood or OPIM that is capable of
releasing these materials during handling; contaminated sharps; and pathological and microbiological
wastes containing blood or OPIM. Regulated waste includes medical waste regulated by California Health
and Safety Code, Chapter 6.1.
1.
Discarding and containing contaminated sharps
Discard contaminated sharp instruments immediately in containers that are:
 Closable;
 Puncture resistant;
 Leak-proof on the sides and bottom; and
 Color-coded red and labeled “biohazard” in a manner that distinguishes the container.
During use, containers for contaminated sharp instruments must be:
 Easily accessible and located as close as possible to the area where sharp instruments
are used or can be reasonably anticipated to be found;
 Maintained upright throughout use; and
 Replaced routinely and not over-filled.
In this facility, containers for contaminated sharp instruments are located:
Red Sharps containers are located: At benches and in all procedure areas
When moving containers of contaminated sharps from the usage area, the container must be:
 Closed prior to removal or replacement to prevent spillage or exposing the contents during
handling, storage, transport or shipping.
 Placed in a secondary container if leakage is possible. The secondary container must
meet the same specifications and be similar to the primary container. Do not move the
contents from one container to another.
Reusable containers must not be opened, emptied or cleaned in any manner that would expose
you to risk of puncture injury.
2.
Other regulated waste
Other regulated waste means:
a.
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 other body fluid that is visibly contaminated with blood such as saliva or
vomitus, and all body fluids in situations where it is difficult or impossible to differentiate
between body fluids such as emergency response;
b.
Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and
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c.
HIV-containing cell or tissue cultures, organ cultures; HIV-, HBV- or HCV-containing
culture medium or other solutions; and blood, organs or other tissues from experimental
animals infected with HIV, HBV or HCV.
Be sure to distinguish these and other potentially infectious waste from general refuse and
garbage.
Disposal requirements include placing waste in containers that are:
 Closable;
 Constructed to contain all contents and prevent leakage of fluids during handling, storage,
transport or shipping;
 Color-coded “red” and labeled “biohazard” to properly identify the container as being used
for potentially contaminated medical waste; and,
 Closed prior to removal to prevent spillage or exposure of contents during handling,
storage, transport or shipping.
If the regulated waste container becomes contaminated on the outside, place that container in a
second container that meets the same standards as the primary container. Do not move the
contents of one container to another.
3.
Laws regulating medical waste disposal
Disposal of all regulated waste must be in accordance with the California Medical Waste
Management Act (California Health & Safety Code, Chapter 6.1). This code defines medical waste
as (a) biohazardous waste or sharps waste or (b) waste which is produced as a result of the
diagnosis, treatment or immunization of human beings or animals, in research or in the production
or testing of biologicals.
F.
Laundry procedures
The following provisions are specified to minimize exposures when handling contaminated laundry:
 Those handling contaminated laundry should be trained.
 Handle laundry as little as possible with a minimum of agitation.
 Disposable clothing should be used whenever possible.
 Laundry must be containerized/bagged at the location where it was used. It should not be sorted,
washed or rinsed in the location of use.
 Contaminated clothing should be disinfected using bleach by someone trained in the handling of
medical waste.
 Place and transport laundry in bags labeled or color-coded to appropriately identify it as
contaminated material.
 Whenever contaminated laundry is wet and presents a likelihood of soak-through or leakage,
place it in separate plastic bags.
 Supervisors must ensure that employees who have contact with contaminated laundry wear
protective gloves and other appropriate PPE.
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Step four: Develop guidelines for HIV, HBV and HCV research
laboratories
Does this lab conduct known HIV, HBV, HCV research?
Yes (applicable)
No (not applicable)
Requirement source: The standard
In addition to other requirements, research and production facilities engaged in the culture, production,
concentration, experimentation and manipulation of HIV, HBV and HCV ... shall meet the following criteria:
Standard Microbiological Practices and special practices. This does not apply to clinical or diagnostic
laboratories engaged solely in the analysis of blood, tissues or organs.
Title 8, CCR Section 5193 California Code of Regulation
Implementation
All UC Davis laboratories engaged in the culture, production, concentration, experimentation and
manipulation of HIV, HBV and/or HCV must submit an Application for Use of Biological Agents and a
Protocol for Use of Biological Agents to the Institutional Biosafety Committee (IBC). Biosafety forms are
available on the Environmental Health & Safety (EH&S) Web site at http://ehs.ucdavis.edu. You must also
complete the appropriate sections of Appendix IV.
Tasks and Procedures
Laboratory doors must be kept closed when working with HIV, HBV or HCV. Access to the work area
should be limited to authorized persons. Written policies and procedures should be established so only
persons who have been advised of the potential biohazards, meet specific requirements and comply with
entry and exit procedures should be allowed to enter work areas and animal rooms. When OPIM or
infected animals are present in the work area, a hazard warning sign incorporating the universal biohazard
symbol should be posted on the door. Vacuum lines should be protected with liquid disinfectant traps and
HEPA filters. Hypodermic needles and syringes should be used only for parenteral injection and aspiration
of fluids from laboratory animals. Only needle-locking syringes or disposable syringes should be used for
injections. All spills should be immediately contained and cleaned up. Written biosafety procedures should
be prepared and adopted.
The employer will assure that employees have prior experience in the handling of human pathogens or
tissue culture before working with HIV, HBV or HCV. The employer will provide training to employees who
have no prior experience in handling human pathogens.
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Appendix IV
A.
HIV, HBV and HCV research laboratories
All UC Davis laboratories engaged in the culture, production, concentration, experimentation and
manipulation of HIV, HBV and/or HCV are required to comply with special provisions in addition to other
requirements contained in this plan. These provisions are included in the guidelines established by the
National Institutes of Health and the Centers for Disease Control and Prevention (refer to Biosafety Levels
two and three in “Biosafety in Microbiological and Biomedical Laboratories”). PIs or instructors who would
like to engage in activities using HIV, HBV or HCV must obtain authorization from the IBC. Be sure to
complete the Biological Use Authorization Application, which can be obtained from the Office of
Environmental Health & Safety (EH&S) Web site at http://ehs.ucdavis.edu.
.
Location of containers for disposing of contaminated sharps:
Building:
Room:
The following list of biohazardous waste can be found at this facility:
1.
2.
3.
Laboratory “red bag” solid waste
Laboratory “red sharps” waste
Laboratory Pathology waste for incineration only
This work is covered by:
BUA No.:
Department:
Principal Investigator:
Phone:
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Step five: Establish a plan for providing hepatitis B vaccinations, postexposure evaluations and follow-up
Requirement source: The standard
The employer shall make available the hepatitis B vaccine and vaccination series to all employees who
have occupational exposure as well as post exposure evaluation and follow-up to all employees who have
had an exposure incident. However, designated first-aid providers who have occupational exposure do not
have to be offered the pre-exposure hepatitis B vaccine if their primary job assignment is not the rendering
of first aid.
Title 8, CCR Section 5193 California Code of Regulation
Implementation
Hepatitis B vaccinations will be provided by the Employee Health Services (Sacramento Campus 916-7343572) or Occupational Health (Davis Campus 530-752-2330). You may decline the vaccination by
completing the Waiver Form (Form 5b).
The Principal Investigator (PI) or supervisor will follow up on any exposure incident. The Occupational
Medicine Physician at the Occupational Health Clinic will provide medical evaluations for employees on the
Davis Campus. The Employee Health Physician at Employee Health Services Clinic will provide medical
evaluations for employees on the Sacramento Campus. Be sure to complete the appropriate sections of
Appendix V.
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Appendix V: Hepatitis B vaccinations, post-exposure evaluations and follow-up
A.
Hepatitis B vaccination
The hepatitis B vaccine and vaccination series is available to all employees who have occupational
exposure. These vaccinations are available at no cost to you. They are administered by the Occupational
Health Clinic (Davis Campus) and the Employee Health Services Clinic (Sacramento Campus). The PI/lab
must obtain and keep either a vaccination consent form for each employee as preferred by the David
Campus (Form 5a), a copy of each employee’s vaccination record indicating a Hepatitis B titer has been
achieved as preferred by the Sacramento Campus or documentation of exception as indicated below.
You will receive the vaccinations after you have received the initial occupational exposure training and
within 10 working days of initial assignment to a position involving potential exposure.
Exceptions to our vaccination policy may be granted if you:
 Have previously received the complete hepatitis B vaccination series (proof is required);
 Are immune from the hepatitis B virus as established by documented antibody testing;
 Cannot take the vaccine for medical reasons (documentation of contraindications is required); or
 Sign a statement annually declining to accept the hepatitis B vaccination (Form 5b).
If you initially decline the hepatitis B vaccination but at a later date decide to accept the vaccination, we
will, at that time, make the hepatitis B vaccination available to you. Be sure to sign the vaccination consent
form for hepatitis B (Form 5a).
If, at a future date, a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public
Health Service, we will make those booster dose(s) available to you at no cost.
B.
Post-exposure evaluation and follow-up
A post-exposure evaluation and follow up will be made for all employees who have had an exposure
incident. These medical evaluations and procedures are available at no cost to you.
You must notify your PI
(name)
as soon as a
suspected exposure incident has occurred. Following an exposure report, we will immediately make
available to you a confidential medical evaluation and follow up (contact Employee Health Services). This
medical attention includes:
 Documentation of the route(s) of exposure and the circumstances under which the exposure
incident occurred; and
 Identification and documentation of the source individual (unless identification is not feasible or is
prohibited by law.
If the exposure is from a human source, the individual’s blood will be tested as soon as feasible (and after
that individual’s consent is obtained) in order to determine HBV, HIV or HCV existence. If consent cannot
be obtained, we must document that fact. When the source individual’s consent is not required by law, that
individual’s blood, if available, will be tested and the results documented. When the source individual is
already known to be infected with HBV, HIV or HCV, this testing need not be performed.
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Results of the source individual’s testing will be made available to the exposed employee. Applicable laws
and regulations concerning disclosure of the identity and infectious status of the source individual will be
provided.
If you suspect exposure, a blood specimen will be drawn as soon as possible and tested. If you consent to
baseline blood collection but do not consent to HIV serologic testing, the sample will be preserved for at
least 90 days. If within 90 days of the exposure incident, you elect to have the baseline blood sample
tested, testing will be done as soon as feasible.
Post-exposure prophylaxis (when medically indicated, as recommended by the U.S. Public Health
Service), counseling and evaluation of subsequent reported illnesses will also be provided.
A physician will work closely with the supervisor to evaluate and follow an exposed employee. The
physician will be provided with a copy of the appropriate sections of this exposure-control plan and
supporting government regulations to make him or her aware of our responsibilities. We will also provide
that physician with a description of the exposed employee’s duties as they relate to the exposure incident,
documentation of the routes of exposure, circumstances under which exposure occurred, results of the
source individual’s blood testing (if available), and all medical records relevant to the appropriate treatment
including vaccination status.
The exposed employee will be provided with a written evaluation from the treating physician within 15 days
of the completion of the physician’s evaluation. That report will contain:
 The physician’s opinion as to whether hepatitis B vaccination is indicated for the employee and if
the employee has received the vaccination;
 A statement that the employee has been informed by the physician of the results of the evaluation;
 A statement that the employee has been told about any medical conditions resulting from
exposure to blood or Other Potentially Infectious Materials (OPIM) that require further evaluation or
treatment.
All other findings or diagnoses will remain confidential and will not be included in the written report to us.
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Form 5a: Consent for hepatitis B vaccination
I have read or someone has read to me the information on this sheet about hepatitis B and the hepatitis B vaccine.
I have been given the opportunity to ask questions, which were answered to my satisfaction. I understand that if I
get sick during the four weeks after receiving the vaccine, I should immediately report this fact to my physician. I
believe I understand the benefits and risks of the hepatitis B vaccine and request that it be given to me.
Date
Printed name of person to receive vaccine
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Signature
Form 5b: Waiver of hepatitis B vaccine
I understand that, due to my occupational exposure to blood or Other Potentially Infectious Materials (OPIM), I may
be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with
hepatitis B vaccine at no charge/cost to myself. However, I decline hepatitis B vaccination at this time. I understand
that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I
continue to have occupational exposure to blood or OPIM and I want to be vaccinated with the hepatitis B vaccine,
I can receive the vaccination series at no charge to me.
Date
Employee’s printed name
Employee’s signature
Date
Employer representative’s printed name
Employer representative’s signature
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Step six: Establish a hazard communication system
Requirement source: The standard
Warning labels should be affixed to containers of regulated waste, refrigerators and freezers containing
blood or other potentially infectious materials and other containers used to store, transport or ship blood or
other potentially infectious material.
Title 8, CCR Section 5193 California Code of Regulation
Implementation
Biohazard warning labels must be placed on contaminated equipment, regulated waste, refrigerators,
freezers and shipping containers. Items that should be labeled must be listed in Appendix VI.
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Appendix VI
A.
Hazard communications and emergency response
1.
Warning labels and signs
“Biohazard” warning labels must be attached or affixed to:
 Contaminated equipment;
 Containers of regulated waste;
 Refrigerators, freezers, -80 degree freezers, liquid nitrogen freezers, and cryogenic
material storage vessels containing blood, human cell lines, human source materials or
Other Potentially Infectious Material (OPIM); and
 Other containers used to store, transport or ship blood, human cell lines, human source
materials or OPIM except as noted, below.
A sample label appears on the following page. This label must be fluorescent orange with lettering
in a contrasting color. The labels must be attached with adhesive or another method that prevents
their loss or unintentional removal.
Items that require warning labels include, but are not limited to:
 Refrigerators/freezers/-80 degree freezers and cryogenic material storage vessels;
 Laundry bags;
 Disposable needles/sharp instruments containers;
 Reusable sharp instruments containers;
 Contaminated pieces of equipment (or portions thereof);
 Biocabinets used with human source material or OPIM;
 Containers for transporting human source material or OPIM;
 Containers for handling specimens; and
 Containers of regulated wastes.
Biohazard Label
BIOHAZARD
HAZARD IDENTITY:
BH302
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Exceptions to these labeling requirements are permitted when:
 Red bags or red containers with the biohazard symbol are used in lieu of labels, and those
red bags/containers are used for nothing else;
 Containers of blood, blood components or blood products are labeled as to their contents
and have been released for transfusion or other clinical use and are so identified;
 Individual containers of blood or OPIM are placed together in a labeled container during
storage, transport, shipment or disposal; or
 Regulated waste has been decontaminated.
2.
Steps to take in an Emergency
An emergency is a situation in which an employee is exposed to potentially infectious material on
any exposed/unprotected part of his/her body, regardless of whether the exposed body part has
any known cuts, scratches, open lesions or exposed mucous membranes.
If an emergency involving blood or OPIM should occur, the following actions should be taken:
 The affected employee must immediately clean the blood or OPIM from his/her exposed
body with soap and water followed by a disinfectant. If the eyes should be exposed, they
should immediately be flushed with running water for 15 minutes.
 The affected employee must, as soon as feasible, clean and disinfect/decontaminate any
surfaces in the immediate work environment that may exposure any other employee or
patient.
 The affected employee must, as soon as feasible, report the incident to
his/her supervisor (name),
, who
will visually observe the affected employee’s exposed body area to confirm the
presence/absence of cuts, scratches, open lesions or exposed mucous membranes
around the affected area. If any cuts, scratches, open lesions or exposed mucous
membranes are found or suspected, contact Employee Health Services (follow “Postexposure Evaluation and Follow-up,” Appendix V).
 The P.I. or researcher, etc. will document and follow up the event by reporting it through
steps required by Injury Illness Prevention Program (IIPP).
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Step seven: Develop methods to provide information and training to
employees
Requirement source: The standard
Employers shall ensure that all employees with occupational exposure participate in a training program
which must be provided at no cost to the employee during working hours. Training records shall be
maintained for three years from the date on which training occurred.
Title 8, CCR Section 5193 California Code of Regulation
Implementation
The department must establish a training program to satisfy this requirement. This training must occur at
the time of initial assignment where occupational exposure may occur and annually thereafter. Additional
training should be provided when changes in duties or procedures occur.
Communication with employees must be appropriate in content and vocabulary to educational level,
literacy and language. Appendix VII describes the requirements of an effective training program.
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Appendix VII
A.
Information and training
1.
General
Initial and periodic training is required to be provided by the employer for all employees who may
have any occupational exposure as a result of their employment. The training is provided at no
cost to the employee during normal working hours. Training is provided as follows:
 At the time of initial assignment to tasks where occupational exposure may take place;
and
 Annually thereafter.
The PI/supervisor will ensure that training is provided to employees.
All employees will participate in the initial and annual training sessions (forms 7a and 7b)
regardless of whether an employee may have received recent training about bloodborne
pathogens. Additional training will be given when changes such as modification of tasks or
procedures or when new tasks or procedures affect employees’ occupational exposure.
An attendance record is made and retained for all employees in attendance at training sessions.
Also, a record will be made and retained of those employees who should have but did not attend a
session. A make-up session, if needed, will be provided at a convenient time within 10 days of the
missed session.
2.
Training Content
The training program consists of the following elements and materials:
 A copy of the OSHA standards supporting your exposure-control plan;
 A review of your exposure-control plan, with copies available;
 An explanation of the Cal-OSHA standard;
 A general discussion of applicable bloodborne diseases and their transmission;
 An explanation of the use and limitations of methods that will prevent or reduce
exposures, including appropriate environmental measures, work practice routines and
protective equipment;
 Information on the types, selection, proper use, location, removal, handling,
decontamination and disposal of Personal Protective Equipment (PPE);
 Emergency response procedures involving blood or Other Potentially Infected Material
(OPIM);
 An explanation of the post-exposure evaluation and follow-up;
 Information on how to handle exposure incidents;
 An explanation of the signs, labels, and/or color-coding used in the practice to identify
potentially infectious material; and
 Information on the hepatitis B vaccine.
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B.
Training records
Records pertaining to training programs are maintained at least three years and include:
 The dates of all training programs (scheduled, make-up, annual and impromptu);
 The contents, summary or minutes of each session;
 The name and position/qualification of the person conducting the training; and
 The attendance rosters, reflecting names and job titles of all persons attending the sessions.
All training records will be maintained by the PI/supervisor and will be available for inspection and copying
by the employee, employee representatives and by regulatory inspectors.
1.
Record Availability
All records concerning our exposure control program will be made available upon request to
agents and representatives of the Department of Labor and the Occupational Safety and Health
Administration for examination and copying.
Employee training records will be provided for examination and copying (upon request), to
employees.
Employee hepatitis B vaccination and medical records will be provided on written request for
examination and copying to the subject employee and representatives of Cal-OSHA.
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Form 7a: Initial/annual training documentation and class sign-up sheet
Date:
Trainer’s name:
Subjects covered:
Work location building:
Room No.
Attendees, please print your name legibly in order to receive credit for your training.
Printed name
Signature
Employee/student ID No.
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Form 7b: Individual employee training documentation
Initial training
Trainer’s name:
Employee’s name:
Employee/student ID:
Training subject:
Hire/assignment date:
I (signature)
hereby certify that I received training as described
in the following areas and agree to comply with these requirements and safe work practices:
 A copy of the OSHA standards supporting our exposure-control plan;
 A review of the laboratory or unit exposure-control plan with copies available;
 An explanation of the Cal-OSHA standard;
 A general discussion of bloodborne diseases and their transmission;
 An explanation of the use and limitations of methods that will prevent or reduce exposures, including
appropriate environmental measures, work practice routines and protective equipment;
 Information on the types, selection, proper use, location, removal, handling, decontamination and disposal
of Personal Protective Equipment (PPE);
 Emergency response procedures involving blood or Other Potentially Infected Materials (OPIM);
 An explanation of the post-exposure evaluation and follow-up;
 Information on how to handle exposure incidents;
 An explanation of the signs, labels and/or color-coding used in the practice to identify potentially infectious
material; and
 Information on the hepatitis B vaccine.
All attendees are urged to participate and ask questions during training sessions. If any questions cannot be
answered at the time, they will be researched and responded to promptly.
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Step eight: Establish and maintain medical records
Requirement source: The standard
The employer shall establish and maintain an accurate record for each employee with occupational
exposure.
Title 8, CCR Section 5193 California Code of Regulation
Implementation
UC Davis Employee Health Services will maintain medical records for employees at UCDHS/Sacramento Campus
and Occupational Health Services will maintain medical records for employees at the Davis Campus.
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Appendix VIII
A.
Record Keeping
1.
Medical Records
Employee Health Services (Sacramento Campus) and Occupational Health Services (Davis
Campus) maintain medical records for each employee with occupational exposure. Each record
includes:
 The name and Social Security Number of the employee;
 A record of the employee’s hepatitis B vaccination status, including the dates;
 A record of the information provided to the physician, relative to exposure and the
surrounding circumstances;
 A record of all results of examinations, medical tests and follow-up; and
 A confidential record of the physician’s written opinion regarding the exposed employee.
All medical records will be secured at Employee Health Services and will remain confidential.
Contents of medical records will not be disclosed or reported without the employee’s specific
written consent to any person within or outside the work place except as required by law or for the
employee’s medical well-being.
By law, we will maintain employees’ medical records (or arrange for their transfer) for at least the
duration of employment plus 30 years.
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