Site-Specific Bloodborne Pathogen
Non-Laboratory Exposure Control Plan
Program Scope
The Northeastern University Exposure Control Plan (ECP) describes how to eliminate or minimize
the exposure of personnel to human blood, blood products and other potentially infectious
material (OPIM) that may contain bloodborne pathogens (BBP). The ECP is available on the Office
of Environmental Health and Safety website for review and downloading. This document provides
site-specific information about how the ECP will be carried out in specific areas and supplements
the university ECP.
Responsibilities: Each supervisor of non-laboratory environments will:
1. Complete this site-specific ECP based on the activities performed in his/her facilities. The
plan will remain on file in a central location within the laboratory or workplace along with
other safety documents. A copy will be submitted to the Biosafety Program Manager each
year to ensure the plan is updated annually.
2. Consider sharps safety devices annually. A review of devices must be completed every year
and should involve staff members that work with the sharps. The “Safety Needle/Sharps
Annual Review Form” and “Sharps Safety Device Evaluation Form” should be completed
each year and retained for record keeping purposes.
3. Assure that faculty, staff and students are referred to complete the Bloodborne Pathogens
training provided by EHS at the time of initial assignment and annually thereafter.
4. All eligible faculty, staff and students will be offered the hepatitis B vaccine. Each employee
must fill out a “Hepatitis B Vaccination Verification/Declination Form”. This form will be
kept on file in the Office of Environmental Health and Safety.
5. Refer employees who would like to get the hepatitis B vaccine to contact the Office of
Environmental Health and Safety. Employees may choose to accept the hepatitis B vaccine
at any time.
Prepared by
Date Completed
Phone
Number
Date of annual
review and update
Building
Room Number(s)
Principal
Investigator
Department
Person Responsible
for ECP
Location of
ECP
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Category I
This includes workers with job related tasks or procedures that have the potential to
involve contact or exposure to mucous membranes with blood or OPIM. This can include
the potential for spills or splashes. Activities include research, teaching and clinical work
that involves the use of human blood or OPIM.
Personnel and/or job title with expected occupational exposure
Category II
This includes workers with job related tasks or procedures that do not normally involve
planned exposure to human blood or OPIM. Potential exposure may result from unplanned
tasks and may be a condition of employment.
Personnel and/or job title with possible exposure
Check all material used in your work area that may result in employee exposure to
bloodborne pathogens.
Source Material of Potential Bloodborne Exposure
Human Blood
Cells/Tissues/Organ Cultures – Human
Human Blood Components
Body fluids with blood (e.g. saliva, vomitus)
Human Blood Products
All body fluids-can’t differentiate fluids
Unfixed Human Tissues
Other:
Unfixed Human Organs
Other:
Culture Growth Media Solutions
Other:
Experimental Animal Blood/Tissues
Other:
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Procedures/tasks with potential
exposure
Personal Protective Equipment (PPE)
required
Safety glasses
Goggles
Face shield
Lab coat
Disposable gown
Coveralls
Surgical Mask
Gloves: Click here to select type
Safety glasses
Goggles
Face shield
Lab coat
Disposable gown
Coveralls
Surgical Mask
Gloves: Click here to select type
Safety glasses
Goggles
Face shield
Lab coat
Disposable gown
Coveralls
Surgical Mask
Gloves: Click here to select type
Safety glasses
Goggles
Face shield
Lab coat
Disposable gown
Coveralls
Surgical Mask
Gloves: Click here to select type
Safety glasses
Goggles
Face shield
Lab coat
Disposable gown
Coveralls
Surgical Mask
Gloves: Click here to select type
Safety glasses
Goggles
Face shield
Lab coat
Disposable gown
Coveralls
Surgical Mask
Gloves: Click here to select type
Safety glasses
Goggles
Face shield
Lab coat
Disposable gown
Coveralls
Surgical Mask
Gloves: Click here to select type
3
Engineering and Work Practice Controls
Please check the appropriate methods of compliance below.
Engineering controls – Specify when each is used
Incineration box lined with 2 red biohazard bags covered with a plastic lid
Sharps container:
Tongs or forceps to handle broken glass:
Other (describe):
Sharps containers are inspected,
Whenever necessary to prevent
maintained and replaced:
overfilling (no more than 2/3 full)
By:
Every:
Sharps container decontamination and
disposal procedure:
Containers for reusable sharps
information and protocol for securing
and removing
Sharps injury log
See Appendix A
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Work practice controls used to minimize exposure; in conjunction with universal
precautions
No eating or drinking, applying
Reusable sharps are secured
cosmetics or contact lenses in areas
immediately when not in use (explain how
with human materials (blood and/or
and where these are stored):
OPIM)
Wear protective footwear
No capping, bending or shearing
needles
Contaminated sharps are
Additional work practice controls
immediately placed in sharps container (explain):
No mouth pipetting
Change gloves whenever soiled, torn
or punctured
Remove gloves before exiting the lab
or clinical environment
Follow procedures for proper
removal and disposal of PPE
Training on use of engineering
controls required prior to working in
Specimens are transported in
secondary, non-breakable, leak proof,
sealed and labeled containers when
taken outside of the lab
Wash hands when gloves are
removed or changed, whenever gloves
become soiled or contaminated and
before leaving the work area
How are all personnel and supervisors involved in identifying changes in
engineering controls and work practices and evaluating new products or process
improvements?
Employee feedback (explain):
Exposure incident investigation:
Other (specify and explain):
Name of person responsible for
implementing engineering controls and
work practice recommendations
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Personal Protective Equipment (PPE)
Please indicate the appropriate methods of compliance below.
Location of PPE
Person responsible for providing PPE
Procedure for removal and handling of used
PPE
List articles that are laundered
Person responsible for laundry & name of
company
How are articles prepare for laundry and
what is the laundry schedule?
Decontamination Procedure
Potentially contaminated surfaces and equipment shall be decontaminated at the end of
each work shift. Use the table below to identify your laboratory/workplace cleaning
schedule.
Disinfectant
(concentration)
Contact time
(minutes)
Spill and decontamination procedures (specify disinfectant and contact time)
Handwashing Facilities
Hand washing facilities shall be made available and readily accessible however where
handwashing facilities are not feasible, antiseptic cleanser with clean paper towels will be
available. When antiseptic cleanser is used, employee shall wash his/her hand with soap
and running water as soon as feasible.
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Location of handwashing facilities
and/or antiseptic cleaner
Person responsible for maintaining
supplies and handwashing facility
Waste Disposal
Bloodborne pathogen waste procedure - explain how waste is handled and disposed
of (include PPE):
Person responsible for providing lab
specific BBP training (required before
working with BBP – includes on proper use
of engineering controls)
Person responsible for reviewing exposure
incidents
Emergency Procedures
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Wash area immediately
 Wounds and needlestick: Thoroughly scrub the area for 15 minutes with warm
water and soap.
 Eye and mucous membrane exposure: Flush immediately at nearest eyewash
station for 15 minutes.
Seek care immediately
 While you are treating your exposure area, have a co-worker contact campus police
at (617) 373 – 3333 for help. They will triage you and get you to a medical care
facility for further treatment if necessary.
 Be prepared with information for the healthcare providers. Bring information
about the agent and/or animal or material involved in your injury or exposure. This
information should include agent description, route of exposure, dose and
concentration, and any unusual characteristics of the agent
 Notify your supervisor, PI and the Office of Environmental Health and Safety
__________________________________________________________________________________________
Signature of PI or Lab Manager
Date reviewed & updated
(must be within 12 months of last review/update)
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Appendix A
Sharps Injury Log
PI/Supervisor:
Dates:
Date Entered
Date/Time Type/Brand of
of Incident Device
Department/
Work Area
Incident
Occurred
Description of Incident
Retain until _________________________________________ (Five years after end of log year)
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Safety Needle / Sharps Annual Review Form
All sharps that are being used where there is potential for exposure to bloodborne pathogens
must be reviewed on an annual basis. During your annual review of devices, you must inquire
about new or prospective safer options.
Principal Investigator / Supervisor __________________________________________________
Date ____________________ Department __________________________________________
Extension ________________ Address _____________________________________________
Please fill out the table below with the appropriate information for documentation of:
1. Annual consideration of new safer sharps devices;
2. To determine which sharp devices are currently in use;
3. To document the criteria used in the selection of the safer sharp deice in use.
Sharps Currently in Use
Name of
Sharp
Manufacturer
Size(s) in
Use
Is it a
Safety
Sharp?
Are there
evaluation forms
(or exclusion
memos) on file?
Justification for
selection of
device (enter
N/A if no device
is currently
available)
Principal Investigator / Supervisor Signature _________________________________________
Date _____________________________________________
Sharps Safety Device Evaluation Form
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Principal Investigator / Supervisor:______________________ Evaluation Date:______________
Evaluator’s Name:__________________________________ Job Title:_____________________
Department:______________________________________ Extension:____________________
Name of Device:________________________________________________________________
Name of Manufacturer:___________________________________________________________
Applications of Device:___________________________________________________________
Number of times used:___________________________________________________________
Please circle the most appropriate answer for each question. Not Applicable (N/A) maybe used if
the question does not apply to this product. Please explain all problems with the device in the
comments section.
1. The safety feature can be activated using a one-handed technique.
Agree….Disagree
1 2 3 4 5 N/A
2. The safety feature does not interfere with the normal use of this
product.
1 2 3 4 5 N/A
3. Use of this product requires you to use the safety feature.
1 2 3 4 5 N/A
4. The user’s hands remain behind the needle/sharp until activation
of the safety mechanism is complete.
1 2 3 4 5 N/A
5. A clear and unmistakable change (either audible or visible) occurs
when the safety feature is activated.
1 2 3 4 5 N/A
6. This product does not require more time to use than a non-safety
device.
1 2 3 4 5 N/A
7. The device is easy to handle while wearing gloves.
1 2 3 4 5 N/A
8. The device is easy to handle when wet.
1 2 3 4 5 N/A
9. The safety feature works well with a wide variety of hand sizes.
1 2 3 4 5 N/A
10. The safety feature operates reliably.
1 2 3 4 5 N/A
11. The exposed sharp is permanently blunted or covered after use
and prior to disposal.
1 2 3 4 5 N/A
12. This device will work with all required syringe and needle sizes.
1 2 3 4 5 N/A
13. Use of this product does not increase the number of sticks to
the patient.
1 2 3 4 5 N/A
14. The user does not need extensive training for correct operation.
1 2 3 4 5 N/A
15. The device can be used without causing more patient discomfort
than a conventional device.
1 2 3 4 5 N/A
Sharps Safety Device Evaluation Form
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16. This device offers a good view of any aspirated fluid.
Agree….Disagree
1 2 3 4 5 N/A
17. The product stops the flow of blood after the needle is removed
from the catheter (or after the butterfly is inserted) and just prior
to the line connections or the hep-lock capping.
1 2 3 4 5 N/A
18. It is not easy to skip a crucial step in proper use of the device.
1 2 3 4 5 N/A
Additional Questions for I.V. Connectors:
19. Use of this connector eliminates the need to exposed needles in
connections.
1 2 3 4 5 N/A
20. The safety feature allows you to collect blood directly into a vacuum
tube, eliminating the need for needles.
1 2 3 4 5 N/A
21. The connector can be secured (locked) to Y-sites, hep-locks, and
central lines.
1 2 3 4 5 N/A
Additional Questions for Vacuum Tube Blood Collection Systems:
22. The safety feature works with a butterfly.
23. The inner vacuum tube needle (rubber sleeved needle) does not
present a danger of exposure.
Would you recommend using this device?
1 2 3 4 5 N/A
1 2 3 4 5 N/A
Yes
No
Comments (describe problems, list incompatibilities):___________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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