OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
INSTRUCTIONS
The Model Exposure Control Plan is intended to serve as a guide to the OSHA Bloodborne Pathogens standard. A
central component of the requirements of the standard is the development of an exposure control plan (ECP). The intent
of this model is to provide pediatric offices (primarily solo and small group practices) with an easy-to-use format for
developing their own written exposure control plan. As health care employers, pediatricians will need to adapt the model
for specific use at their medical offices or clinics. The ECP provides general guidance on standard related topics for
pediatric medical offices. Since no two pediatric practices are identical, each facility must customize the model ECP to be
a useful compliance tool. The information in this model ECP should not be considered a substitute for the OSH Act or any
provisions of the OSHA standards.
FOLLOW THESE STEPS TO CREATE A CUSTOMIZED ECP FOR YOUR OFFICE.







Review the OSHA packet from the AAP.
Study the OSHA standards and the federal needlestick prevention provisions, and any applicable state legislation or
regulations.
Complete the worksheets applicable to your office.
Use information from the ECP worksheets to modify the sample ECP document and make it specific to your practice
(customize those portions of the ECP document shaded in gray).
Modify the suggested policy and procedures to reflect your practice's operations. Print, sign and date the
implementation of the ECP. Store in a location readily accessible to all staff.
Train your staff (and document their training) on what the ECP is, where it is located, why it is important, how they
must modify their behavior to comply with the ECP, and what the consequences of failing to comply may be.
Establish an ongoing process and assign responsibilities for implementing, monitoring, enforcing and updating ECP.
1
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
Facility Name:Sparks Pediatric and Adolescent Medicine
Address: 975 Roberta Lane STE 101 B Sparks NV
Plan Prepared by: Kevin M. Windisch MD
Plan Reviewed by:
Next Review Date :
Date: 9-1-03
Date:
The above referenced facility is committed to providing a safe and healthful work environment for our entire staff.
In pursuit of this endeavor, the following exposure control plan (ECP) is provided to eliminate or minimize
occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 C.F.R. 1910.1030,
"Occupational Exposure to Bloodborne Pathogens."
The ECP is a central document to assist our facility in implementing and ensuring compliance with the standard,
thereby protecting our employees.
The ECP includes:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Program Administration
Determination of Employee Exposure
Methods of Implementation and 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 an exposure incident
2
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
I. PROGRAM ADMINISTRATION
Kevin M. Windisch MD
is (are) responsible for the implementation of the ECP.
Kevin M. Windisch MD______________________________________________
will maintain review and update the ECP at least annually, and whenever necessary to include new or modified
tasks and procedures.
359-7111______________________________
Kevin M. Windisch MD
is (are) responsible for the will maintain and provide all necessary personal protective equipment (PPE),
engineering controls (eg sharps containers), labels, and red bags as required by the standards.
359-7111______________________________
Kevin M. Windisch MD
will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes.
CONTACT LOCATION/TELEPHONE NUMBER ___359-7111____________________________________________
Kevin M. Windisch MD
will be responsible for ensuring that all medical actions required are performed and that appropriate employee
health and OSHA records are maintained.
CONTACT LOCATION/TELEPHONE NUMBER ______359-7111_________________________________________
Kevin M. Windisch MD
will be responsible for training, documentation of training, and making the written ECP available to employees,
OSHA, and NIOSH representatives.
CONTACT LOCATION/TELEPHONE NUMBER ___359-7111___________________________________________
3
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
II. EMPLOYEE EXPOSURE DETERMINATION
Complete the employee exposure determination worksheets 1 and 2. Use this information to determine employee
exposure to BBP. Insert information for each job title/classification below.
The following is a list of all job classifications at our establishment in which all employees have occupational
exposure:
JOB TITLE
DEPARTMENT LOCATION
Physician
Assistant
EXAMPLE:
Medical Technician
Clinical laboratory on-site in physician office
The following is a list of job classifications in which some employees at our establishment have occupational
exposure. 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
Housekeeping
EXAMPLE:
Housekeeper
DEPARTMENT/LOCATION
Environmental Services
TASK/PROCEDURE
Clean-up
Handling regulated waste
NOTE: Part-time, temporary, contract and per diem employees are covered by the standards. How the provisions of
standard will be met for these employees should be described in the ECP.
4
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
III. METHODS OF IMPLEMENTATION AND CONTROL
This section outlines universal (ie, general) precautions and specific engineering and work practice controls that that are
in place to protect our employees, as per OSHA regulations. The goal of these methods of implementation and control is
to eliminate or minimize employee exposure to bloodborne pathogens. The information that follows describes the
universal precautions and specific engineering and work practice controls and the dates these practices were instituted in
our facility.
A. UNIVERSAL PRECAUTIONS
DATE INSTITUTED: 9-1-03 9-1-03
All employees will utilize universal precautions.
To reduce exposure to bloodborne pathogens, all human blood and body fluids shall be considered potentially infectious
materials. Precautions must be uniformly used by employees of this facility with all patients regardless of whether their
blood or body fluids are infected.
5
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
B. ENGINEERING AND WORK PRACTICE CONTROLS
9-1-03
DATE INSTITUTED: 9-1-03
Engineering controls are defined as (eg sharps disposal containers, self-sheathing needles, safer medical devices, such
as sharps with that isolate or remove the bloodborne pathogens hazard from the workplace. Devices with engineering
controls shall be identified and evaluated on a regular basis at least annually. The purpose of the evaluation process is to
determine which controls are appropriate for specific hazards, based on what is appropriate to the specific medical
procedures being conducted, what is feasible, and what is commercially available. If there is no safer option for a
particular medical device used where these is exposure to blood or OPIM, the employer is not required to use something
other than the device that is normally used. If a safer device is available and determined to be appropriate for specific
hazards associated with specific medical procedures, then a process for implementing the device should be established.
examined or replaced on a regular schedule to ensure their effectiveness. 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. Engineering controls shall be examined and maintained or
replaced on a regular schedule to ensure their effectiveness.
6
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
The following person or department is responsible for implementing, monitoring, and updating engineering
controls and work practices: __Kevin M. Windisch MD
______________________________________________________
Name
job title
department
1) Exposure Control Plan
Date Instituted: 9-1-03 9-1-03
Employees covered by the bloodborne pathogens standard received an explanation of the ECP during their initial
training session. These employees will receive additional training on the ECP whenever it is significantly
revised; employees will receive ongoing training on ECP at least annually. All employees have an opportunity to
review the ECP at any time during their work shifts by contacting
KEVIN M. WINDISCH MD
If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of receiving
the request.
Kevin M. Windisch MD______________________________________________
is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or
modified tasks/procedures/technology which affect occupational exposure and to reflect new or revised
employee positions with occupational exposure.
7
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
WORK PRACTICES
a) Handwashing
Date Instituted: 9-1-03 9-1-03
Handwashing is required and facilities should be in a readily accessible location. This facility's policy on employee
handwashing is described in our policy and procedure on handwashing.
b) Prohibition of shearing/recapping sharps
Date Instituted: 9-1-03 9-1-03
"Sharps" means anything that can penetrate the skin including needles, scalpels, broken glass, broken capillary tubes,
and exposed ends of dental wires. Shearing or breaking of contaminated sharps is prohibited. Bending, recapping, or
removing contaminated sharps, such as contaminated needles, is also prohibited unless there is no feasible alternative or
such action is required by the specific medical procedure. If removal or recapping is necessary, removal or recapping
must be done either by one-handed scooping (passive recapping) or through a recapping device.
c) Disposal of sharps and reusable sharps
Date Instituted: 9-1-039-1-03
Employees must follow this facility's policy and procedures for disposing of sharps.
Sharps disposal containers are inspected and maintained or replaced by (Name of responsible person or
department) ____Kevin M. Windisch MD___________________________________________________________
every (list frequency) __2 Months___________________________________________________________________
or whenever necessary to prevent overfilling.
Please note the number, type, and location of sharps disposal containers placed in your facility.
TYPE OF SHARPS
CONTAINER
Portable
Wall Mount
LOCATED
REPLACEMENT DATE
MA Station
MA station
8
COMMENTS*
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
d)
Regulated waste
Date Instituted: 9-1-039-1-03
Regulated waste requires special handling and must be placed in appropriate containers.
Regulated waste includes the following:
(1) liquid or semiliquid blood or other potentially infectious material,
(2) items contaminated with blood or other potentially infectious material that would release these substances in a liquid
or semiliquid state if compressed,
(3) items that are caked with blood or other potentially infectious material and are capable of releasing these materials
during handling,
(4) contaminated sharps, and
(5) pathological and microbiological wastes containing blood or other potentially infectious material.
The containers into which regulated waste is stored, transported, or shipped must be closable. The container must also be
constructed so as to contain the waste and prevent leakage of its contents. If the waste could puncture the primary
container, the primary container must be placed into a puncture-resistant secondary container. If outside contamination of
the primary container occurs, the primary container must also be placed within a second container that prevents leakage.
For containment requirements of sharps, see the section "Disposal of Sharps and Reusable Sharps."
Indicate below the types of regulated waste that are generated in the facility (eg, gloves, gowns, soiled laundry,
gauze/bandages), the type of containers in which the waste is disposed, and the label placed on each container (see
"Labeling").
WASTE
Biohaz Waste
PRIMARY CONTAINERS FOR REGULATED WASTE
LOCATION
CONTAINER
Closet
LABEL
Indicate below where you have placed secondary containers to avoid possible exposure in situations in which the outside
of the primary container becomes contaminated. Secondary containers must meet the same requirements of the primary
containers.
WASTE
Bags
SECONDARY CONTAINERS FOR REGULATED WASTE
LOCATION
CONTAINER
Closet
9
LABEL
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
e) Labeling
The following labeling method(s) is used in this facility:
Labels are used to warn employees who may have contact with containers of the potential hazard posed by their
contents. Labels must be attached to containers of regulated waste, to refrigerators and freezers containing blood and
other potentially infectious materials, and to other containers used to store, transport, or ship blood or other potentially
infectious materials. The warning label must be fluorescent orange or orange-red, contain the biohazard symbol and the
word BIOHAZARD in a contrasting color, and be attached to each object by string, wire, adhesive, or another method to
prevent loss or unintentional removal of the label.
Labels are not required, however, in the following situations:
(1) when red bags or containers are used;
(2) when 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
(3) when individual containers of blood or other potentially infectious materials are placed in a labeled container during
storage, transport, shipment, or disposal.
10
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
e) Labeling (continued)
The grid below may be helpful in developing your facility's labeling policy and procedure.
CATEGORY
ITEM OR EXAMPLE
BIOHAZARD
LABEL
RED
CONTAINER
REGULATED WASTE
CONTAINER
CONTAMINATED SHARPS
CONTAINER
YES
YES
REUSABLE
CONTAMINATED
SHARPS CONTAINER
CONTAMINATED SURGICAL
INSTRUMENTS SOAKING IN A
TRAY
YES
YES
REFRIGERATOR/
FREEZER
USED FOR STORING BLOOD OR
OPIM
YES
YES
YES
INDIVIDUAL
SPECIMEN
CONTAINERS OF
BLOOD OR OPIM *
YES
YES
HEMATOLOGY TESTING DEVICE
YES
YES
REGULATED WASTE
SHIPPED FROM
PRIMARY FACILITY TO
ANOTHER FACILITY
FOR DISPOSAL
YES
YES
YES
YES
LAB COATS WITH BLOOD
STAINS OR OPIM
9-1-03
9-1-03
9-1-03
9-1-03
YES
plus a label
indicated where
the
contamination
exists
SPECIMENS SHIPPED
FROM PRIMARY
FACILITY TO
ANOTHER FACILITY
FOR SERVICE
OR TESTING
CONTAMINATED
LAUNDRY
9-1-03
9-1-03
CONTAINERS USED
FOR STORAGE,
TRANSPORT,
SHIPPING BLOOD
CONTAMINATED
EQUIPMENT NEEDING
SERVICE
DATE IMPLEMENTED
9-1-03
9-1-03
9-1-03
INDIVIDUAL CONTAINERS NEED NOT BE LABELSED OR COLOR-CODED AS BIOHAZARDS IF THEY ARE "PLACE IN A LABELED CONTAINER
DURING STORAGE, TRANSPORT, SHIPMENT OR DISPOSAL." 29 C.F.R. §1910.1030 (g) (I) (G).
11
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
e) Labeling (continued)
Kevin M. Windisch MD __________________________________________________________
will ensure warning labels are affixed or red bags are used as required if regulated waste or contaminated
equipment is brought into the facility. Employees are to notify ___________________________________________
Kevin M. Windisch MD they discover regulated waste containers, refrigerators containing blood or OPIM,
contaminated equipment, etc. without proper labels.
g) Eating, drinking, smoking, applying cosmetics
Date Instituted: 9-1-03
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas when
there is any risk of occupational exposure. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets, or
on countertops where blood or other potentially infectious materials are present.
h) Performing procedures involving blood
Date Instituted: 9-1-03
All procedures involving blood or other potentially infectious material must be performed in such a manner as to minimize
splashing, spraying, splattering, and generation of droplets of these substances.
12
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
3. PERSONAL PROTECTIVE EQUIPMENT
Personal protective equipment must be used to prevent blood or other potentially infectious material from passing through
to, or contacting the employees' work or street clothes, undergarments, skin, eyes, mouth, or other mucous membranes,
unless engineering controls and work practices have eliminated occupational exposure. An employee may temporarily
decline wearing personal protective equipment under rare and extraordinary circumstances. Rare and extraordinary
circumstances arise when, in the employee's professional judgment, use of protective equipment will prevent the delivery
of health care or public safety services or pose an increased hazard to workers. This exception is intended to apply in
essentially life-threatening situations. Incidents during which an employee elects not to wear protective equipment must
be documented by the employer to determine whether changes can be instituted to prevent occurrence in the future.
The financial responsibility for purchasing the personal protective equipment rests with the employer. The employer is not
obligated to provide general work clothes to employees. The type and amount of equipment shall be chosen to protect
against contact with blood or other potentially infectious material based upon the type of exposure and quantity of these
substances that can be reasonably anticipated to be encountered during the performance of a task or procedure. If
laboratory coats or uniforms are intended to protect the employee's body from contamination, they are to be provided by
the employer. Laboratory coats and uniforms that are used as personal protective equipment shall be laundered by the
employer and not sent home with the employee for cleaning. All personal protective equipment shall be:
removed prior to leaving the work area, removed as soon as possible following penetration by blood or other infectious
materials, and placed in a designated area or container for storage, washing, decontamination, or disposal.
PERSONAL PROTECTIVE EQUIPMENT (PPE)
DATE INSTITUTED: 9-1-03
PPE is provided to our employees at not cost to them. Training is provided by Kevin M. Windisch
MD___________________________________________________________________________________
In the use of the appropriate PPE for the tasks or procedures employees will perform.
The types of PPE available to employees are as follows:
A. Disposable Gloves
Date Instituted: 9-1-03
Employees must wear appropriate gloves when it can be reasonably anticipated that the employee may have contact with
blood (eg, suturing, immunizations and other potentially infectious materials and when handling or touching contaminated
items or surfaces).
Indicate below the location of disposable gloves and circumstances in which gloves are to be worn.
Location of Gloves
Each exam room
MA station
Closet
Circumstances to be Used
Exposure to BBP
13
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
B. Disposable Gloves (powderless, liners, non-latex)
Date Instituted: 9-1-03
Employees with latex sensitive skin performing tasks, which require the use of disposable gloves may request that nonlatex or powderless, or lined disposable gloves be made available to them. The employer will make gloves for latex
sensitive employees available to these employees free of charge in the appropriate sizes. Indicate below where gloves for
latex sensitive employees are available in the facility.
Location of Gloves
MA Station
Circumstances to be Used
Potential exposure to BBP
C. Utility Gloves
Date Instituted: 9-1-03
Utility gloves are to be worn by employees performing tasks described in our housekeeping policy and procedure. Utility
gloves may be decontaminated for reuse if the integrity of the glove is not compromised. However, they must be
discarded if they are cracked, peeling, torn, punctured or exhibit other signs of deterioration. Employees are required to
check utility gloves for cracks or other flaws as noted above and replace as necessary.
Location of Gloves
Closet
Circumstances to be Used
Cleaning of toilets, emesis
D. Masks, Eye Protection and Face Shields
Date Instituted: 9-1-03
Employers must make available to employees masks, eye protection, and face shields to protect the mucous membranes
of the face and upper respiratory tract from droplet splattering. Minimum protection should consist of a mask in
conjunction with eye glasses with solid side shields or a chin-length face shield.
E. Personal Protective Clothing
Date Instituted: 9-1-03
Use of protective body clothing, such as gowns, aprons, laboratory coats, clinic jackets, surgical caps, or shoe covers,
and the degree to which such protective equipment must resist penetration, are performance based. The employer must
evaluate the task and the type of exposure anticipated and, based on the determination, select the appropriate personal
protective clothing. For example, laboratory coats and gowns with long sleeves shall be used for procedures in which
exposure of the forearm to blood or other potentially infectious material is reasonably anticipated to occur.
Personal Protective Clothing (continued)
Indicate below which type of protective clothing is required in your facility, and under what circumstances the protective
clothing is required.
14
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
_____Gloves, Mask Eye protection, impermeable gown_____________________________________________
_________________________________________________________________________________________________
_____________________________________________________________________________________________
_______________________________________________________________________________________________
Examples: gloves, eye protection, etc
PPE is located _Closet____________________________________________________________ and may be
obtained through Kevin M. Windisch MD
All employees using PPE must observe the following precautions:







Wash hands immediately or as soon as feasible after removal of gloves or other PPE.
Remove PPE after it becomes contaminated, and before leaving the work area.
Used PPE may be disposed of in (specify here) ______Biohaz trash if contaminated___________
(List appropriate containers for storage, laundering, decontamination or disposal.)
Wear appropriate gloves when it can be reasonable 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,
contaminated 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 away as to
avoid contact with the outer surface.
15
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
Personal Protective Equipment (continued)
For example: how and where to decontaminate face shields, eye protection, resuscitation equipment. Indicate below
which type of protective equipment is required in your facility, and the circumstances indicating that PPE must be used.
PROCEDURES/TASKS
NONE
Patient examination
Burn treatment/dressing
Wound treatment/dressing
Cerumen removal
Foreign body removal
I and D abscess
Laceration repair
Suture removal
Lumbar puncture
Hematoma subungual
IM injection (eg vaccines,
allergy, epinephrine)
Lab specimen
collection/handling
 Finger stick
 Heel stick
 Venipuncture
Laboratory testing
 Hematology tests
 Urine tests*
IV therapy
Ear piercing
Changing diapers*
Handling regulated waste:
Other:
Other:
xxx
DISPOSABLE
GLOVES
UTILITY
GLOVES
FACE
MASK
FACE
SHIELD
GLASSES WITH SIDE
SHIELDS/GOGGLES
OTHER
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
Xxx
Xxx
Xxx
Xxx
NA
NA
xxx
xxx
* where the presence of blood is visible or suspected
F. Resuscitation/Respiratory Equipment
Date Instituted: 9-1-03
Resuscitation/respiratory devices should be readily available and accessible to employees who can be reasonably
expected to resuscitate a patient. Emergency ventilation devices also fall under the scope of protective personal
equipment and hence must be provided by the employer for use in resuscitation (eg, masks, mouthpieces, resuscitation
bags, shields/ overlay barriers).
16
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
HOUSEKEEPING
DATE INSTITUTED: 9-1-03
REGULATED WASTE is placed in container which are closable, constructed to contain all contents and prevent
leakage, appropriately labeled or color-coded (see Labels) and closed prior to removal to prevent spillage or
protrusion of contents during handling.
The procedure for handling SHARPS DISPOSAL CONTAINERS is: (may refer to specific agency procedure by
title or number and last date of review).
The procedure for handing OTHER REGULATED WASTE is: (may refer to specific agency procedure by title or
number and last date of review.
CONTAMINATED SHARPS are discarded immediately or as soon as possible in containers that are closable,
puncture-resistant, leakproof on sides and bottoms, and labeled or color-coded appropriately. Sharps disposal
containers are available at: (must be easily accessible and as close as feasible to the immediate area where
sharps are used).
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
BINS AND PAILS (eg, wash or emesis basins) are cleaned and decontaminated as soon as feasible after visible
contamination.
BROKEN GLASSWARE, which may be contaminated, is picked up using mechanical means, such as a brush and
dust pan.
17
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
LAUNDRY
DATE INSTITUTED: 9-1-03
The following contaminated articles will be laundered by this facility:
_________NONE__________________________________________________________________________________
_
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Laundering will be performed by Kevin M. Windisch MD FAAP
_________________________________________________________________________________________________
_________________________________________________________________________________________________
at (time and/ or location)
_______________________Launderomat____________________________________________________________
_________________________________________________________________________________________________
The following laundering requirements must be met:


Handle contaminated laundry as little as possible, with minimal agitation
Place wet contaminated laundry in leakproof, labeled or color-coded containers before transport. Use (red
bags or other other bags for this purpose) _______________________________________________________;
and
 Wear the following PPE when handling and/or sorting contaminated laundry: (list appropriate PPE on lines
below)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
18
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
LABELS
CATEGORY
ITEM OR EXAMPLE
BIOHAZARD
LABEL
RED
CONTAINER
REGULATED WASTE
CONTAINER
CONTAMINATED SHARPS
CONTAINER
YES
YES
REUSABLE
CONTAMINATED
SHARPS CONTAINER
CONTAMINATED SURGICAL
INSTRUMENTS SOAKING IN A
TRAY
YES
YES
REFRIGERATOR/
FREEZER
USED FOR STORING BLOOD OR
OPIM
YES
YES
YES
INDIVIDUAL
SPECIMEN
CONTAINERS OF
BLOOD OR OPIM *
YES
YES
HEMATOLOGY TESTING DEVICE
YES
YES
REGULATED WASTE
SHIPPED FROM
PRIMARY FACILITY TO
ANOTHER FACILITY
FOR DISPOSAL
YES
YES
YES
YES
YES
YES
LAB COATS WITH BLOOD
STAINS OR OPIM
CONTAMINATED
LAUNDRY SENT TO
ANOTHER FACILITY
THAT DOES NOT USE
UP
9-1-03
9-1-03
9-1-03
9-1-03
YES
plus a label
indicated where
the
contamination
exists
SPECIMENS SHIPPED
FROM PRIMARY
FACILITY TO
ANOTHER FACILITY
FOR SERVICE
OR TESTING
CONTAMINATED
LAUNDRY
9-1-03
9-1-03
CONTAINERS USED
FOR STORAGE,
TRANSPORT,
SHIPPING BLOOD
CONTAMINATED
EQUIPMENT NEEDING
SERVICE
DATE IMPLEMENTED
9-1-03
9-1-03
9-1-03
9-1-03
*INDIVIDUAL CONTAINERS NEED NOT BE LABELED OR COLOR-CODED AS BIOHAZARDS IF THEY ARE "PLACED IN A LABELED
CONTAINER DURING STORAGE, TRANSPORT, SHIPMENT OR DISPOSAL." 29 C.F.R. §1910.1030 (g) (I) (G).
IV.
HEPATITIS B VACCINATION
19
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
Kevin M. Windisch MD FAAP
will provide training to employees on hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods
of administration, and availability.
The hepatitis B vaccination series is available at not cost after training and within 10 days of initial assignment to
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 chooses to decline vaccination, the employee must sign a declination form. Employees
who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the
vaccination is kept at DR. Windisch’s Office
Following hepatitis B vaccinations, the health care professional's Written Opinion will be limited to whether the
employee requires the hepatitis B vaccine, and whether the vaccine was administered.
See worksheet 10
20
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
V.
POST-EXPOSURE EVALUATION AND FOLLOW-UP
Should an exposure incident occur, contact Kevin M. Windisch MD
_________________________________________________________________________________________________
at the following telephone number: __________________________________________________________________
___________________________________359-7111___________________________________________________
An immediately available confidential medical evaluation and follow-up will be conducted by The facility listed by
our Workers’ Compensation insurer as listed at the time of the incident.
After the initial first aid (eg, clean the wound, flush eyes or other mucous membrane, etc) the following activities
will be performed:

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 exposed 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 th source individual's test results and with the
information about applicable disclosure laws and regulations concerning the identify and infectious status of
the source individual (eg, laws protecting confidentiality).

After obtaining consent, collect exposed employee's blood as soon feasible after exposure incident, and test
blood for BVC and HIV serological status

If the employee does not give consent for HIV serological testing durinct collection of blood for baseline
testing, preserve the baseline blood sample fore at least 90 days; if the exposed employee elects to have he
baseline sample tested during thi waiting period, perform testing as soon as feasible.
21
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
VI. ADMINISTRATION OF POST-EXPOSURE EVALUATION AND FOLLOW-UP
Kevin M. Windisch MD__________________________________________________________
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.
Kevin M. Windisch MD__________________________________________________________
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
Kevin M. Windisch MD__________________________________________________________
provides the employee with a copy of th evaluating health care professionals written opinion within 15 days after
completion of the evaluation.
PROCEDURES FOR EVALUATING THE CIRCUMSTANCES SURROUNDING AN EXPOSURE INCIDENT
Kevin M. Windisch MD__________________________________________________________
will review the circumstances of all exposure incidents to determine:







engineering controls in use at the time
work practices followed
a description of the device being used
protective equipment of clothing that was used at the time of the exposure incident (gloves, eye shields, etc)
location of the incident (eg, hallway, examining room, laboratory, etc)
procedure being performed when the incident occurred
employee's training
If it is determined that revisions need to be made,
Kevin M. Windisch MD________________________________________________________ will ensure that
appropriate changes are made to this ECP. (Changes may include an evaluation of safer devices, adding
employees to the exposure determination list, etc).
See worksheet 7
22
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
VI.
ADMINISTRATION OF POST-EXPOSURE EVALUATION AND FOLLOW-UP (continued)
EMPLOYEE TRAINING
All employees who have occupational exposure to BBP receive training conducted by
Kevin M. Windisch MD__________________________________________________________
(Attach a brief description of their qualifications.)
All employees who have occupational exposure to BBP receive training on the epidemiology, symptoms, and
transmission of bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the
follow elements:



A copy and explanation of the standard
An explanation of our ECP and information on how to obtain a copy of it
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 limitation of engineering controls, work practices and PPE
An explanation of 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 person 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 facility
An opportunity for interactive questions and answers with the person conducting the training session





Training materials for this facility are available at _________________________________________________.
23
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
VI.
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 ___________________________________________________________________________
(Name of person responsible or location of records) ___________________________________________________.
The training records include:
 The dates of the training sessions
 The content or a summary of the training sessions
 The names and qualifications of person 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 15 working days of receiving the request. Such requests should be addressed to
________________________________________________________________________________________
(Name of person or department responsible).
MEDICAL RECORDS
Medical records are maintained for each employee with occupational exposure to BBP in accordance with 29 C.F.
R. 1910.20 "Access to Employee Exposure and Medical Records."
________________________________________________________________________________________
Kevin M. Windisch MD FAAP is responsible for maintenance of the required medical records. These confidential
records are kept at 975 Roberta Lane STE 101 B Sparks NV 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 within30 working days of receiving the request. Such requests should be sent to
Kevin M. Windisch MD FAAP 975 Roberta Lane STE 101 B Sparks NV 89431
OSHA RECORDKEEPING
An exposure incident is evaluated to determine if the case meets OSHA's Recordkeeping Requirements (29
C.F.R. 29 1904). This determination and the recording activities are done by Kevin M. Windisch MD FAAP
24
OSHA BLOODBORNE PATHOGENS STANDARD
Exposure Control Plan
(h)(5) Sharps Injury Log.
(i)
The employer shall establish and maintain a sharps injury log for the recording of percutaneous injuries
from contaminated sharps. The information in the sharps injury log shall be recorded and maintained in
such manner as to protect the confidentiality of the injured employee. The sharps injury log shall
contain, at a minimum:
(A)
the type and brand of device involved in the incident,
(B)
the department or work area where the exposure incident occurred, and
(C)
an explanation of how the incident occurred.
(ii)
The requirement to establish and maintain a sharps injury log shall apply to any employer who is
required to maintain a log of occupational injuries and illnesses under 29 CFR 1904.
(iii)
The sharps injury log shall be maintained for the period required by 29 CFR 1904.6.
SOURCE: 29 C.F.R. § 1910.1030 Bloodborne Pathogens (h) (5)
25