UW Colleges
Bloodborne Pathogens Exposure Control Plan
February 27, 2015
POLICY
The UW Colleges are committed to providing a safe and
healthful work environment for our entire staff. In pursuit of this
goal, the following exposure control plan (ECP) is provided
to eliminate or minimize occupational exposure to bloodborne
pathogens in accordance with OSHA standard 29 CFR 1910.1030,
“Occupational Exposure to Bloodborne Pathogens.”
The ECP is a key document to assist our organization in
implementing and ensuring compliance with the standard, thereby
protecting our employees. This ECP includes:
■ Determination of employee exposure
■ Implementation of various methods of exposure control,
including:
Universal precautions
Engineering and work practice controls
Personal protective equipment
Housekeeping
■ Hepatitis B vaccination
■ Post-exposure evaluation and follow-up
■ Communication of hazards to employees and training
■ Recordkeeping
■ Procedures for evaluating circumstances surrounding exposure
Incidents
Implementation methods for these elements of the standard are
discussed in the subsequent pages of this ECP.
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PROGRAM ADMINISTRATION
■ The Campus Assistant Dean for Administration and Finance (ACDAF)
is responsible for implementation of the ECP. The ACDAF and the UW
Colleges Risk Manager will maintain, review, and update the ECP at least
annually, and whenever necessary to include new or modified tasks
and procedures. Contact location/phone number: UW Colleges Risk
Manager @ 608-265-0621
■ Those employees who are determined to have occupational
exposure to blood or other potentially infectious materials (OPIM)
must comply with the procedures and work practices outlined in
this ECP.
■ The Building and Grounds Superintendent will provide and
maintain all necessary personal protective equipment (PPE),
engineering controls (e.g., sharps containers), labels, and red bags
as required by the standard. The Building and Grounds Superintendent will
ensure that adequate supplies of the aforementioned equipment are
available in the appropriate sizes. Contact location/phone number: Building
and Grounds Superintendent respective phone number
_________________________ .
■ The ACDAF will be responsible for ensuring that all medical actions
required by the standard are performed and that appropriate employee
health and OSHA records are maintained. Contact location/phone
number: ACDAF’s respective phone number_______________________
■ UW Colleges Risk Manager will be responsible for training,
documentation of training, and making the written ECP
available to employees, OSHA, and NIOSH representatives.
Contact location/phone number: Madison Office 608-265-0621.
EMPLOYEE EXPOSURE DETERMINATION
The following is a list of the primary job classifications at our establishment
in which all employees have occupational exposure, others may be added
to meet a campuses needs:
Job Title
Department/Location
Building and Grounds Superintendent
Maintenance
Custodian
Maintenance
Facility Repair Worker
Maintenance
Custodial Supervisor
Maintenance
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HVAC Specialist
Laborer
Athletic Director
Coaches
Lab Technicians
Lab Professors
Maintenance
Maintenance
Athletics
Athletics
Academics
Academics
The following is a list of the primary job classifications in which some
employees at our establishment have occupational exposure, others may
be added to meet a campuses needs. Included is a list of tasks and
procedures, or groups of closely related tasks and procedures, in which
occupational exposure may occur for these individuals:
Job Title Department/Location Task/Procedure
Building and Grounds Superintendent
Custodian
Facility Repair Worker
Custodial Supervisor
HVAC Specialist
Laborer
Athletic Director
Coaches
Lab Technicians
Lab Professors
Maintenance
Maintenance
Maintenance
Maintenance
Maintenance
Maintenance
Athletics
Athletics
Academics
Academics
All have the potential for body fluid clean up and handling regulated waste.
METHODS OF IMPLEMENTATION AND CONTROL
Universal Precautions
All employees will utilize universal precautions.
Exposure Control Plan
Employees covered by the bloodborne pathogens standard
receive an explanation of this ECP during their initial training
session. It will also be reviewed in their annual refresher training.
All employees can review this plan at any time during their work
shifts by contacting Building and Grounds Superintendent. If
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requested, we will provide an employee with a copy of the ECP
free of charge and within 15 days of the request. UW Colleges Risk
Manager is responsible for reviewing and updating the ECP annually or
more frequently if necessary to reflect any new or modified tasks and
procedures that affect occupational exposure and to reflect new or revised
employee positions with occupational exposure.
Engineering Controls and Work Practices
Engineering controls and work practice controls will be used to
prevent or minimize exposure to bloodborne pathogens. The specific
engineering controls and work practice controls used are listed below:
■ _Sharps disposal containers
■ _Lab trays designated for sharps__
Sharps disposal containers are inspected and maintained or
replaced by the Custodial Department daily to prevent overfilling.
This institution identifies the need for changes in engineering
controls and work practices through review of OSHA
records, employee interviews, committee activities, etc.
We evaluate new procedures and new products regularly by literature
review, supplier information, and best practices from other sites or
industries.
Both front-line workers and management officials are involved
in this process in the following manner: Campus Safety Committee review.
The Building and Grounds Superintendent is responsible for
ensuring that these recommendations are implemented.
Personal Protective Equipment (PPE)
PPE is provided to our employees at no cost to them. Training in
the use of the appropriate PPE for specific tasks or procedures is
provided by the Buildings and Grounds Superintendent. This training will be
at least annually and upon hire of new staff. Note: State contract online
training can also be used.
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The types of PPE available to employees are as follows:
Gloves, Eye protection, Spill Kits, Gowns and Face protection as needed.
PPE is located in the Maintenance Office and may be obtained through
contacting the Building and Grounds Superintendent or Custodial staff.
PPE supplies will be monitored and re ordered as needed by the Building
and Grounds Superintendent.
All employees using PPE must observe the following precautions:
■ Wash hands immediately or as soon as feasible after removing
gloves or other PPE.
■ Remove PPE after it becomes contaminated and before leaving
the work area.
■ Used PPE may be disposed of in a proper impervious bag and taken to
the Building and Grounds office for disposal.
■ Wear appropriate gloves when it is reasonably anticipated that
there may be hand contact with blood or OPIM, and when handling
or touching contaminated items or surfaces; replace gloves if torn,
punctured or contaminated, or if their ability to function as a barrier
is compromised.
■ Utility gloves may be decontaminated for reuse if their integrity
is not compromised; discard utility gloves if they show signs of
cracking, peeling, tearing, puncturing, or deterioration.
■ Never wash or decontaminate disposable gloves for reuse.
■ Wear appropriate face and eye protection when splashes,
sprays, spatters, or droplets of blood or OPIM pose a hazard to the
eye, nose, or mouth.
■ Remove immediately or as soon as feasible any garment contaminated
by blood or OPIM, in such a way as to avoid contact with the outer surface.
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.
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The procedure for handling sharps disposal containers is:
Remove container and tape all openings, replace with a new container,
take full container to the Building and Grounds Superintendent for proper
disposal.
The procedure for handling other regulated waste is:
Ensure that all waste is in an impervious bag and take the waste the
Building and Grounds Superintendent for proper disposal.
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 at the Building and Grounds
Superintendent office.
Bins and pails (e.g., wash or emesis basins) are cleaned and
decontaminated as soon as feasible after visible contamination.
Broken glassware that may be contaminated is only picked up
using mechanical means, such as a brush and dustpan.
Laundry
The following laundering requirements must be met:
■ handle contaminated laundry as little as possible, with minimal
agitation
■ place wet contaminated laundry in leak-proof, labeled or color-coded
containers before transport. Use red bags for this purpose.
■ wear the following PPE when handling and/or sorting contaminated
laundry: Gloves and gown as needed.
Labels
The following labeling methods are used in this institution:
Use of red bags for all waste or contaminated items.
The Building and Grounds Superintendent is responsible for
ensuring that warning labels are affixed or red bags are used as
required if regulated waste or contaminated equipment is brought
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into the institution. Employees are to notify the Building and Grounds
Superintendent if they discover regulated waste containers,
refrigerators containing blood or OPIM, contaminated equipment,
etc., without proper labels.
HEPATITIS B VACCINATION (Flowchart Attachment F)
*NOTE – All confidential documents will be maintained in a file such as a
Sharepoint or other electronic method.
ACDAF in conjunction with supervisor will ensure training is provided to
pre-determined employees (page 2) on hepatitis B vaccinations,
addressing safety, benefits, efficacy, methods of administration, and
availability.
The hepatitis B vaccination series is available at no cost 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.
However, if an employee declines the vaccination, the employee must sign
a declination form (Attachment A). Employees who decline may
request and obtain the vaccination at a later date at no cost.
Documentation of refusal of the vaccination is kept on file by ACDAF.
Vaccination will be provided by the employees physician or by a location
specified by ACDAF (List health care professional responsible for this part
of the plan) at (location). A tracking form of vaccine doses is provided if the
institution chooses, not required (Attachment B).
Following the medical evaluation, a copy of the health care professional’s
written opinion (Attachment C) will be obtained and provided to the
employee within 15 days of the completion of the evaluation. It will be
limited to whether the employee requires the hepatitis vaccine and whether
the vaccine was administered. A copy of this evaluation must be provided
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to the ACDAF and kept on file. The ACDAF will send a copy of the written
opinion to Central Office Human Resources Department.
POST-EXPOSURE EVALUATION AND FOLLOW-UP (Flowchart Attachment
G)
Should an exposure incident occur, contact the ACDAF at the following
number __(respective ACDAF’s phone number) .
Following initial first aid (clean the wound, flush eyes or other mucous
membrane, etc.), the following activities will be performed:
An immediately available confidential medical evaluation and
follow-up will be conducted by the employees physician or at clinic
recommended by ACDAF (name of licensed health care professional).
Form letter to provide to the Physician is attached (Attachment D).
Items included in the form letter:
■ Document the routes of exposure and how the exposure
occurred.
■ Identify and document the source individual (unless the
employer can establish that identification is infeasible or prohibited
by state or local law).
■ Obtain consent and make arrangements to have the source
individual tested as soon as possible to determine HIV, HCV, and
HBV infectivity; document that the source individual’s test results
were conveyed to the employee’s health care provider.
■ If the source individual is already known to be HIV, HCV and/or
HBV positive, new testing need not be performed.
■ Assure that the exposed employee is provided with the source
individual’s test results and with information about applicable
disclosure laws and regulations concerning the identity and
infectious status of the source individual (e.g., laws protecting
confidentiality).
■ After obtaining consent, collect exposed employee’s blood as
soon as feasible after exposure incident, and test blood for HBV and
HIV serological status
■ If the employee does not give consent for HIV serological testing
during collection of blood for baseline testing, preserve the baseline
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blood sample for at least 90 days; if the exposed employee elects to
have the baseline sample tested during this waiting period, perform
testing as soon as feasible.
ADMINISTRATION OF POST-EXPOSURE
EVALUATION AND FOLLOW-UP
ACDAF will have the employee or assist the employee with completing an
Employee Work Injury and Illness Report, form UWS/OSLP-1Emp (attached).
ACDAF ensures that health care professional(s) responsible for employee’s
hepatitis B vaccination and post-exposure evaluation and follow-up are
given a copy of OSHA’s bloodborne pathogens standard.
ACDAF ensures that the health care professional evaluating an employee
after an exposure incident receives the following:
■ a description of the employee’s job duties relevant to the
exposure incident
■ route(s) of exposure
■ circumstances of exposure
■ if possible, results of the source individual’s blood test
■ relevant employee medical records, including vaccination status
Personal physician provides the employee with a copy of the evaluating
health care professional’s written opinion within 15 days after completion of
the evaluation (Attachment E). A copy of the written opinion will be
provided to the Central Office Human Resources, Workers Compensation
Coordinator.
PROCEDURES FOR EVALUATING THE CIRCUMSTANCES
SURROUNDING AN EXPOSURE INCIDENT
ACDAF will complete the Employer’s First Report of Injury or Disease form
(attached).
The employee Supervisor or ACDAF will complete the Supervisor’s Accident
Analysis and Prevention Report (attached).
ACDAF will review the circumstances
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of all exposure incidents to determine:
■ 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 incident (gloves, eye shields, etc.)
■ location of the incident (O.R., E.R., patient room, etc.)
■ procedure being performed when the incident occurred
■ employee’s training
UW Systems Workers Compensation Coordinator will record all
percutaneous injuries from contaminated sharps in a Sharps Injury Log.
If revisions to this ECP are necessary the ACDAF and UW Colleges Risk
Manager will ensure that appropriate changes are made.
(Changes may include an evaluation of safer devices, adding
employees to the exposure determination list, etc.)
EMPLOYEE TRAINING
All employees who have occupational exposure to bloodborne
pathogens receive initial and annual training conducted by
UW Colleges Risk Manager, Buildings and Grounds Superintendent or via
the State online training program.
All employees who have occupational exposure to bloodborne
pathogens receive training on the epidemiology, symptoms, and
transmission of bloodborne pathogen diseases. In addition, the
training program covers, at a minimum, the following elements:
■ a copy and explanation of the OSHA bloodborne pathogen
standard
■ an explanation of our ECP and how to obtain a copy
■ an explanation of methods to recognize tasks and other activities
that may involve exposure to blood and OPIM, including what
constitutes an exposure incident
■ an explanation of the use and limitations of engineering
controls, work practices, and PPE
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■ an explanation of the types, uses, location, removal, handling,
decontamination, and disposal of PPE
■ an explanation of the basis for PPE selection
■ information on the hepatitis B vaccine, including information on
its efficacy, safety, method of administration, the benefits of being
vaccinated, and that the vaccine will be offered free of charge
■ information on the appropriate actions to take and persons to
contact in an emergency involving blood or OPIM
■ an explanation of the procedure to follow if an exposure incident
occurs, including the method of reporting the incident and the
medical follow-up that will be made available
■ information on the post-exposure evaluation and follow-up that
the employer is required to provide for the employee following an
exposure incident
■ an explanation of the signs and labels and/or color coding
required by the standard and used at this institution
■ an opportunity for interactive questions and answers with the
person conducting the training session.
Training materials for this institution are available at UW Colleges Risk
Management office and via the state online training program.
RECORDKEEPING
Training Records
Training records are completed for each employee upon
completion of training. These documents will be kept for at least
three years at UW Colleges Risk Manager office, onsite at the Campus and
Central Office Human Resources.
The training records include:
■ the dates of the training sessions
■ the contents or a summary of the training sessions
■ the names and qualifications of persons conducting the training
■ the names and job titles of all persons attending the training
Sessions
Employee training records are provided upon request to the
employee or the employee’s authorized representative within
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15 working days. Such requests should be addressed to
ACDAF and/or UW Colleges Risk Manager
Medical Records
Medical records are maintained for each employee with occupational
exposure in accordance with 29 CFR 1910.1020, “Access to
Employee Exposure and Medical Records.”
The Workers Compensation Coordinator is responsible for forwarding any
medical records in relation to the exposure case to Human Resources and
subsequently UW System Workers’ Compensation Office. These
confidential records are kept in (DOA Worker Comp Records) for at least
the duration of employment plus 30 years.
Employee medical records are provided upon request of the
employee or to anyone having written consent of the employee
within 15 working days. Such requests should be sent to the
ACDAF
OSHA Recordkeeping
An exposure incident is evaluated to determine if the case meets
OSHA’s Recordkeeping Requirements (29 CFR 1904). This determination
and the recording activities are done by UW Colleges Human Resources
and the UW System Office of Workers’ Compensation
Sharps Injury Log
In addition to the 1904 Recordkeeping Requirements, all percutaneous
injuries from contaminated sharps are also recorded in a
Sharps Injury Log. All incidences must include at least:
■ date of the injury
■ type and brand of the device involved (syringe, suture needle)
■ department or work area where the incident occurred
■ explanation of how the incident occurred.
This log is reviewed as part of the annual program evaluation
and maintained for at least five years following the end of the
calendar year covered. If a copy is requested by anyone, it must
have any personal identifiers removed from the report.
Attachment A
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HEPATITIS B VACCINE DECLINATION (MANDATORY)
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 (HBV) infection. I have been given the opportunity
to be vaccinated with hepatitis B vaccine, at no charge 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 other potentially infectious
materials and I want to be vaccinated with hepatitis B vaccine, I can
receive the vaccination series at no charge to me.
Employee Name Printed __________________________________
Employee Signature: _____________________________________
Date Signed: ______________________
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Attachment B
HEPATITIS B VACCINE RECORD
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 (HBV) infection. I have been given the opportunity
to be vaccinated with hepatitis B vaccine, at no charge to myself. I have
elected to receive this vaccination and inform my employer during the three
stages of the vaccination. The vaccination will be completed over a 4 – 6
month period as prescribed by the Center for Disease Control (CDC).
Employee Name Printed __________________________________
Employee Signature: _____________________________________
Date Signed: ______________________
First Dose
_______________________
Second Dose
_______________________
Third Dose
_______________________
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Attachment C
Health Care Professionals Written Opinion For
Administering Hepatitis Vaccine
Health Care Professionals
1.
2.
3.
4.
Employee Name:_____________________________________________
Date of Office Visit:__________________________________________
Health Care Facility Address:__________________________________
Health Care Facility Telephone:________________________________
As required under the Bloodborne Pathogen Standard:
______ Hepatitis B vaccination is ____ is not ____ indicated.
______ Hepatitis B vaccination was ____ was not_____ administered.
Signature of health care provider:_______________________ Date: ________
Printed or typed name of health care provider:___________________________
This form is to be returned to the employer, and a copy provided to the employee within 15 days.
Employer Name:______________________________
Title:_______________________________________
Address:_________________________________________________________
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Attachment D
INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONAL
EVALUATING AN EMPLOYEE AFTER AN EXPOSURE INCIDENT FORM
Dear Healthcare Professional:
One/Some of our employees may have been exposed to bloodborne pathogens
during the performance of their work duties. This individual had direct contact with
potentially infected blood or other potentially infectious materials.
In accordance with the requirements of OSHA's Bloodborne Pathogen Standard,
the exposed employee must immediately have made available to them a confidential
medical evaluation and follow-up which must include at least the following elements:
a. Documentation of the route(s) of exposure, and the circumstances under
which the exposure incident occurred;
b. Identification and documentation of the source individual, unless the UW
Colleges can establish that identification is infeasible or prohibited by state or
local law;
1) The source individual's blood shall be tested as soon as feasible and
after consent is obtained in order to determine HBV and HIV infectivity. If
consent is not obtained, the UW Colleges shall establish that legally
required consent cannot be obtained. When law does not require the
source individual’s consent, the source individual's blood, if available, shall
be tested and the results documented.
2) When the source individual is already known to be infected with HBV or
HIV, testing for the source individual's HBV or HIV status need not be
repeated.
3) Results of the source individual's testing shall be made available to the
exposed employee, and the employee shall be informed of applicable laws
and regulations concerning disclosure of the identity and infectious status
of the source individual.
c. Collection and testing of blood for HBV and HIV serological status;
1) The exposed employee's blood shall be collected as soon as feasible
and tested after consent is obtained.
2) If the employee consents to baseline blood collection, but does not give
consent at that time for HIV serologic testing, the sample shall be
preserved for at least 90 days. If, within 90 days of the exposure incident,
the employee elects to have the baseline sample tested, such testing shall
be done as soon as feasible.
d. d) Post-exposure prophylaxis, when medically indicated, as recommended by the
U.S. Public Health Service;
e. Counseling; and
f. Evaluation of reported illnesses.
-Page 1 of 2-
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INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONAL
EVALUATING AN EMPLOYEE AFTER AN EXPOSURE INCIDENT FORM
In accordance with the requirements of OSHA's Bloodborne Pathogen Standard, you
are being provided with the following information:
a. A copy of the Bloodborne Pathogen Standard (Please pay special attention to
sections 1910.1031 (f)(3 to 5) of the Bloodborne Pathogen Standard if you are
not familiar with this regulation; the indicated sections deal specifically with postexposure evaluation and followup, information provided to the healthcare
professional, and the healthcare professional's written opinion.);
b. A description of the exposed employee's duties as they relate to the exposure
incident);
c. Documentation of the route(s) of exposure and circumstances under which
exposure occurred
d. Results of the source individual's blood testing, if available; and
e. Copies of all medical records relevant to the appropriate treatment of the
employee, including hepatitis B virus vaccination status, which are the UW
Colleges responsibility to maintain.
Please review the provided information and complete the post-exposure evaluation
form. Return the original copy of the completed form to the UW Colleges and give a
copy to the patient within 15 days of the completion of the evaluation.
The healthcare professional's written opinion for post-exposure evaluation and follow-up
(copies attached) must be limited to the following information:
a. That the employee has been informed of the results of the evaluation; and
b. That the employee has been told about any medical conditions resulting from
exposure to
blood or other potentially infectious materials which require further evaluation or
treatment.
All other findings or diagnoses must remain confidential and shall NOT be included in
the written report. If medical follow-up is indicated, please complete the medical followup form for each follow-up visit and return it to the address indicated.
Signature of Company Representative _______________________________
Date:_________________________
Name(s) of Affected Employees:
______________________________________________________________________
______________________________________________________________________
-Page 2 of 2-
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Attachment E
Health Care Professionals Written Opinion For PostExposure Evaluation
Health Care Professionals
1.
2.
3.
4.
5.
Employee Name:_____________________________________________
Date of Incident:_____________________________________________
Date of Office Visit:__________________________________________
Health Care Facility Address:__________________________________
Health Care Facility Telephone:________________________________
As required under the Bloodborne Pathogen Standard:
______ The employee named above has been informed of the results of the post-exposure health evaluation.
______ The employee named above has been told about any health conditions resulting from exposure to
blood or other potentially infectious materials which require further evaluation or treatment.
______ Hepatitis B vaccination is ____ is not ____ indicated.
Signature of health care provider:_______________________ Date: ________
Printed or typed name of health care provider:___________________________
This form is to be returned to the employer, and a copy provided to the employee within 15 days.
Employer Name:______________________________
Title:_______________________________________
Address:_________________________________________________________
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Attachment F
Bloodborne Pathogens (New Hire)
Determine if
employee is part of
the exposure group
Inform employee of
potential exposure
Provide employee a
copy of the
Bloodborne
Pathogens Exposure
Control Plan
Hepatitis B
vaccination series
made available within
10 days of hire
Declination form is
kept on site and send
to Central Office HR
If employee declines
Hep B series they
must complete the
declination form
Medical Evaluation
and Hep B vaccination
documents kept on
site and send to
Central Office HR
Medical evaluation
and Hep B series
provided upon
request.
Emplyee can request
the Hep B series at
anytime after
declining.
New employee is ready for daily tasks
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Attachment G
Bloodborne Pathogens (Post Exposure)
Contact ACDAF
immediately. ACDAF
reviews the BBP written
plan to ensure proper
steps are followed
Physcian provides written
opinion within 15 days of
evaluation to employee
and ACDAF
Incident report forms will
be shared with Worker
Comp. Coordinator
Immediate confidential
medical evaluation
provided for employee
ACDAF/Supervisor
complete the Supervisor's
Accident Analysis and
Prevention Form
Employee provided with
form letter from the BBP
plan to present to
Physician
ACDAF assists employee
with an Employee Work
Injury and Illness Report
ACDAF completes the
Employee First Report of
Injury or Disease Form
ACDAF will provide
Physician a copy of: BBP
Plan, OSHA standard,
routes/circumstances of
exposure, source blood
test if available,
employee medical
records including
vaccination status
ACDAF, Supervisor and Worker Comp. Coordinator
will monitor the employee treatment plan and
progress
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