DEPARTMENT BLOODBORNE PATHOGEN
EXPOSURE CONTROL PLAN
FOR NON-LAB/NON-HOSPITAL STAFF
This plan provides department specific information pertaining to the control of
exposure to bloodborne pathogens and is an Addendum to the University of
Michigan Exposure Control Plan for Non-Hospital, Non-Lab Workers
http://www.oseh.umich.edu/pdf/guideline/plan.pdf
Date of Last Revision:
Department:
Individual Responsible for this Plan:
Departmental staff covered by this plan:
Tasks Performed with Potential for Exposure:
(Administering first aid, CPR, AED)
(Other?__________________)
Delegation of Responsibilities:
OSEH is responsible for the following:
 Review and update of the University Exposure Control Plan
 Conducting training
 Administering the Hep B vaccination program
 Maintaining records of OSEH training

OSEH contact is:__________________
The Department is responsible for:
 Review and update of this Department Exposure Control Plan
 Contacting OSEH for training
 Covering the cost of all preventative Hepatitis B vaccinations
 Keeping PPE and other equipment in stock and available
 Maintaining records of department training, if applicable

Department contact is: _____________________
UM Occupational Health Services is responsible for:
 Administering vaccines
 Conducting all medical evaluations after exposure
 Maintaining all confidential medical records
 Maintaining all vaccination records
Maintaining declination records if requested

UM Occupational Health Services
C380 Med Inn Building
University of Michigan Hospitals
1500 E. Medical Center Drive
Ann Arbor, MI 48109-5835
(734) 764-8021
(734) 998-8788
MON – FRI: 7:30am – 4:30pm
After hours: Emergency Dept. – University of Michigan Hospital
http://www.mhealthy.umich.edu/programs/occupational
Methods of Control:
Controls are intended to minimize the chance of direct contact with blood or
potentially contaminated materials. Methods of control for the tasks listed above
include:
1. Universal Precautions – This is a method of control in which all
human blood and certain body fluids1 are treated as if infectious.
Precautions would be used any time these materials are encountered.
2. Personal Protective Equipment – When practical, wear disposable
gloves before touching blood or contaminated materials and before
initiating emergency patient care tasks where blood is present.
Replace gloves if torn, punctured, contaminated or if their ability to
function as a barrier is compromised. Gloves will not be cleaned for
re-use.
When administering CPR, use a pocket mouth-to-mouth resuscitation
device to prevent direct contact.
1
Blood and certain body fluids include human blood and blood products or components. And saliva in
dental procedures, semen, vaginal secretions, cerebrospinal, synovial, pleural, pericardial, peritoneal,
amniotic fluids, and other body fluids visibly contaminated with blood. Urine and feces are NOT
infectious unless visible blood is present. In labs, other infectious materials include unfixed human tissues
or organs, HIV or Hepatitis B containing cells or cultures. If it is not possible to determine if a body fluid is
one of the above, then treat it as though it is infectious.
If other parts of body come into contact with blood, remove garments
before leaving the scene or as soon as possible thereafter and wash the
contaminated area with soap and water.
3. Work Practices – Handle all sharp objects that may be contaminated
in a manner to prevent puncture of the skin. Wear gloves and use
forceps, tongs or brush and dustpan to collect. Place all sharps in a
puncture resistant, leak-proof container. Label the container as a
“biohazard” and “sharps”.
Shearing or breaking of needles is not permitted. Do not bend,
remove or recap needles.
Used bandages, gauze or contaminated emergency items should be
collected wearing gloves and placed in a biohazard labeled, leak-proof
bag. Double bag the material in another biohazard labeled bag to
ensure no leakage occurs.
Collect all contaminated waste as described above. Remove gloves at
the scene and place in bag with other waste materials.
Wash hands immediately, if possible, or use antiseptic hand cleanser,
clean cloth/paper towels or antiseptic wipes. Wash hands with soap
and water as soon as possible if other means of cleaning were used at
the scene.
4. Clean up of Blood Spills – for those employees assigned to clean up
small amounts of blood, follow the procedures in the attached SOP
(standard operating procedure). (Attachment #1)
5. Disposal and Decontamination of Area – Contact OSEH HazMat
during regular business hours for pick up of all biohazard waste or
for clean up of large spills. Keep biohazard waste in a secure location
in a sealed container until pick up.
6. Emergency equipment: Decontaminate re-useable emergency
equipment before putting back into service.
Ensure that emergency kits are kept stocked and accessible with extra
gloves, pocket mouth-to-mouth devices, a sharps container, biohazard
bags, and other equipment needed for emergencies of this nature.
Hepatitis B vaccination:
All employees covered by this program are offered the hepatitis B vaccination at the
time they are first assigned tasks where there is a potential for exposure. Employees
will be given the attached form (Appendix B) for obtaining the vaccination at UM
Occupational Health Services during work time. There is no need to make an
appointment beforehand.
Employees who choose to decline vaccination must sign a declination form
(Appendix C), which will be kept on record either at the Department or at
Occupational Health Services. Before making a decision, the employee can go to
Occupational Health Services for a consultation with a medical professional who
will explain the advantages and disadvantages of vaccination.
If an employee initially declines the vaccine but at a later date decides to become
immunized, the vaccination series will be made available at that time using the
above procedure.
Exposure incident evaluation and follow up:
An “exposure” to bloodborne borne pathogens takes place when there is an incident
of direct contact of the eye, mouth, mucous membrane or non-intact skin with blood
or products containing blood, while performing an assigned task.
An example of an exposure incident would be a puncture from a contaminated
sharp or a blood splash to the face. A contaminated sharp is something that is able
to puncture the skin and has visible blood or is known to have been in contact with
blood, such as a used needle.
When an exposure incident occurs, the employee will, if possible, carefully retain the
source of the exposure and immediately wash the exposed area with soap and water.
The incident will be reported to the supervisor as soon as possible. The supervisor
will assess the situation to verify that an exposure incident did occur. The
supervisor will complete a Work Connections Injury & Illness form within 24 hours
of the incident (http://www.workconnections.umich.edu/forms.html)
Occupational Health Services will maintain all medical records related to the
incident. As required by law, Occupational Health Services will send a written
opinion to the department, which must be provided to the exposed individual.
Procedures for evaluating circumstances surrounding an exposure incident:
The supervisor will investigate all incidents of exposure to determine if
improvements can be made in the methods of control to prevent future exposure.
OSEH can assist in this process; contact your OSEH rep at 7-1142. The supervisor
will also work with health care professionals in the medical evaluation and follow up
to identify the source of the exposure.
Training:
Employees covered under this program will receive bloodborne borne pathogen
training annually. OSEH staff can provide this training in coordination with the
department. Supervisors can schedule training by calling 647-1142 or by contacting
your OSEH rep directly. Department specific training on the procedures if
applicable, must also be covered either during the OSEH training or at some other
time and place, and records kept.
Recordkeeping:
The following records will be kept accordingly:
Employees covered in this program
The department
Employee Hep B vaccination status
The department
Training records
OSEH & department, if applicable
Hepatitis B vaccination
Occupational Health Services
Vaccination declination form
Occupational Health Services or the
department
Medical evaluations and opinions
Occupational Health Services
Injury & Illness forms, workers comp,
Work Connections
MIOSHA recordkeeping
Last revised: April 2009
Attachment #1
Standard Operating Procedure (SOP) for Cleanup of Small Blood Spills
Follow these procedures for cleaning up spills of blood and blood products. The same
procedures can be used for cleaning up other body fluids. For larger spills that go beyond
your ability to clean with the supplies on hand, contact OSEH HazMat (3-4568 or 911
afterhours).
STEP 1: REQUIRED PERSONAL PROTECTIVE EQUIPMENT
• Prior to beginning the clean up, don a pair of rubber, latex, PVC or similar type gloves.
For small blood spills no other PPE should be required. For larger spills where there is a
possibility of contaminating your face or other parts of your body, call HazMat to perform the
clean up.
STEP 2: SPILL KIT EQUIPMENT
The following items may be needed in handling the spill:
• 10% bleach solution (or Lysol, virex or other EPA reg. Tuberculocidal)
• gloves
• clear plastic bags
• biohazard labels (available from OSEH HazMat)
• leak-proof sharps containers
• brush & dustpan, or tongs or forceps for picking up sharps
• disinfectant wipes
STEP 3: SPILL DECONTAMINATION PROCEDURES
Cover the spill area with a paper towel and then pour freshly mixed 10% bleach and water
solution. Allow solution to soak into the contaminated material. Work from the outside edges of
the spill inward when applying the bleach solution.
Any glass, needles, or other sharp objects that may puncture the skin will not be picked up by
hand. Only mechanical means such as a brush and dustpan, tongs, or forceps are allowed. If you
do not have such equipment available, contact HazMat for clean up.
Wipe up bleached material with paper towels or absorbent pads. It may be necessary to use a
scrub brush to remove the material if it impacted a hard porous surface such as concrete. If nonporous surfaces, such as a carpet have been contaminated, an outside vendor may be needed to
clean the area.
STEP 4: DISPOSAL
Place bleached material, gloves and other disposable materials into a labeled biohazard bag and
place into either another labeled biohazard bag or container. Ensure lids are firmly sealed on all
waste containers when spill cleanup is complete and call HazMat for a pickup (3-4568). Keep
biohazard waste container in a secured area until received by HazMat.
STEP 5: DECONTAMINATE RE-USEABLE EQUIPMENT
Decontaminate with the bleach solution all potentially contaminated re-useable tools or protective
equipment used in the cleanup. This includes dustpans, brooms, forceps, buckets, etc. Anything
that cannot be effectively cleaned (bleach solution must be able to make contact with all surfaces)
must be disposed as waste. After the contaminated area has been cleaned, use fresh water to
remove bleach residue from all surfaces.
STEP 6: WASH YOUR HANDS.
If hand-washing facilities are not available at the job site use disinfectant wipes and then wash
your hands as soon as possible.
BIOHAZARD EXPOSURE
If you believe you were exposed (skin puncture or splash to eyes or mucous membranes) to
biohazard material that had not been decontaminated with the bleach solution follow these
recommended steps:
• Skin exposure: Vigorously wash affected skin with plenty of soap and water while
removing contaminated clothing and shoes.
• Eye exposure: Wash eyes for at least 10 minutes with copious amounts of water, lifting the
upper and lower eyelids occasionally.
• Seek follow-up medical attention by contacting your supervisor for referral to the UM
Occupational Health Services clinic (998-8788)