SUBJECT:
SAFETY
Bloodborne Pathogens
And
Exposure Control Plan
PAGE: 1
OF: 7
DEPARTMENT: ALL
EFFECTIVE: June 2009
(Also Refer to the Hazardous Communication PI)
APPROVED BY: Lab Safety Committee
REVISED: 11/25/11
ALWAYS KEEP IN MIND THAT THE BEST WAY TO PREVENT BLOODBORNE PATHOGENE EXPOSURE IS
PREVENTION; WEAR YOUR PERSONNEL PROTECTIVE EQUIPMENT AND FOLLOW UNIVERSAL PRECAUTIONS!
1.0
POLICY
The Cary institute of Ecosystem Studies is 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 (BBP) 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 – where required
 Post-exposure evaluation and follow-up
 Communication of hazards to employees and training
 Recordkeeping
 Procedures for evaluating circumstances surrounding exposure incidents
This procedure does address precautions to take to prevent exposure to BBP, it does not address your
potential exposure to other more serious bloodborne pathogene disease that have no cure or vaccine such
as HIV.
2.0
PROGRAM ADMINISTRATION
Safety Officer is responsible for implementation of the ECP and 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. In addition, the SO will be responsible for training
and all training records.
Human Resource Manager 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.
3.0
EMPLOYEE EXPOSURE DETERMINATION
The following are job task which have occupational exposure:
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SUBJECT:
SAFETY
Bloodborne Pathogens
And
Exposure Control Plan
PAGE: 2
DEPARTMENT: ALL
OF: 7
EFFECTIVE: June 2009
(Also Refer to the Hazardous Communication PI)
APPROVED BY: Lab Safety Committee
REVISED: 11/25/11
Job Task: Custodial Staff, Safety
The following are job classifications in which some employees have occupational exposure.
NOTE: Part-time, temporary, contract and per diem employees are covered by the bloodborne
pathogens standard. The ECP should describe how the standard will be met for these employees.
4.0
METHODS OF IMPLEMENTATION AND CONTROL – UNIVERAL PRECAUTIONS
Universal precautions state that ALL bodily fluids are to be treated as contaminated. This means if
you encounter blood, urine, mucous and feces. You must assume that it is contaminated and protect
yourself with the required personnel protective equipment (PPE).
4.1 Exposure Control Plan
Employees covered by the bloodborne pathogens standard receive an explanation of this ECP
during their initial safety orientation training session and are required to complete the online
training module. All employees can review this plan at any time during their work shifts by
accessing the Cary Institute of Ecosystem Studies Intranet, clicking on ‘safety’ and then
clicking on ‘Policy and Procedures’. If requested, you can also speak directly with the Safety
Officer.
The Safety Officer 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.
4.2 Personal Protective Equipment (PPE)
All types of PPE are provided to our employees at no cost to them. Training in the
use/donning of the appropriate PPE for specific job tasks based on the hazard assessment is
provided by the Safety Officer and also located through the online training program.
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 ‘red’ containers labeled ‘BIOHARD’ or placed in the ‘red’
BIOHAZARD bags located in all spill kits and first aid kits throughout the property.

Never wash or decontaminate disposable gloves for reuse.
11/25/11
SUBJECT:
SAFETY
Bloodborne Pathogens
And
Exposure Control Plan
PAGE: 3
DEPARTMENT: ALL
OF: 7
EFFECTIVE: June 2009
(Also Refer to the Hazardous Communication PI)
APPROVED BY: Lab Safety Committee

REVISED: 11/25/11
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.

5.0
HEPATITIS B VACCINATION
The Safety Officer will provide training to employees on hepatitis B vaccinations, addressing safety,
benefits, efficacy, methods of administration, and availability.
The hepatitis B vaccination series consist of three vaccine injections given over 6 months and are
available at no cost to the employee. One to two months after the last vaccination is given a blood
test will be done to determine if the individual is immune. However, it is incorrect to assume that
everyone who has been vaccinated is immune. 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.
6.0
POST-EXPOSURE EVALUATION AND FOLLOW-UP
Should an exposure incident occur institute the Cary Institute emergency notification system by
dialing the Operator (O), then contact your Scientist in Charge and the Human Resource Director
x109.
Following the initial first aid (clean the wound, flush eyes or other mucous membrane, etc.),
document the routes of exposure.
7.0
EMPLOYEE TRAINING
All employees receive initial and annual training conducted by the Safety Officer or by completing the
Cary Institute of Ecosystem online training module for Bloodborne Pathogens.
Training materials for this facility are available on line on the intranet or the Safety Officer’s office.
8.0
RECORDKEEPING
Training Records Training records are completed for each employee, upon completion of training.
These documents will be kept for at least three years in the Cary Institute training database
managed by the Safety Officer.
The training records include:



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The dates of the training sessions
The contents or a summary of the training sessions
The name of person conducting the training
SUBJECT:
SAFETY
Bloodborne Pathogens
And
Exposure Control Plan
PAGE: 4
OF: 7
DEPARTMENT: ALL
EFFECTIVE: June 2009
(Also Refer to the Hazardous Communication PI)
APPROVED BY: Lab Safety Committee

REVISED: 11/25/11
The name 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. Such requests should be addressed to
Safety Officer.
9.0
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 Human Resource Manager.
10.0 Sharps Injury Log
In addition to the 1904 Recordkeeping Requirements, all puncture related injuries from contaminated sharps
are also recorded in a Sharps Injury Log. All incidences must include at least:
-
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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.
SUBJECT:
SAFETY
Bloodborne Pathogens
And
Exposure Control Plan
PAGE: 5
DEPARTMENT: ALL
OF: 7
EFFECTIVE: June 2009
(Also Refer to the Hazardous Communication PI)
APPROVED BY: Lab Safety Committee
11.0
REVISED: 11/25/11
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.
Signed: (Employee Name)________________ Date:________________
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Bloodborne Pathogens
And
Exposure Control Plan
SUBJECT:
SAFETY
PAGE: 6
OF: 7
DEPARTMENT: ALL
EFFECTIVE: June 2009
(Also Refer to the Hazardous Communication PI)
APPROVED BY: Lab Safety Committee
REVISED: 11/25/11
EXPOSURE CONTROL LOG
Date
11/25/11
Location
Devise
Explanation of the Incident
Bloodborne Pathogens
And
Exposure Control Plan
SUBJECT:
SAFETY
PAGE: 7
DEPARTMENT: ALL
OF: 7
EFFECTIVE: June 2009
(Also Refer to the Hazardous Communication PI)
APPROVED BY: Lab Safety Committee
REVISED: 11/25/11
In an emergency situation involving blood or potentially infectious materials, you should always use
Universal Precautions and try to minimize your exposure by wearing PPE such as but not limited to:
gloves, splash goggles, pocket mouth-to-mouth resuscitation masks, and other barrier devices.
If you are exposed, however, you should:
1. Wash the exposed area thoroughly with soap and running water. Use non-abrasive, antibacterial
soap if possible.
o If blood is splashed in the eye or mucous membrane, flush the affected area with running
water for at least 15 minutes.
2. Report the exposure to your supervisor as soon as possible and inform the Safety Officer so an
Exposure Report Form can be completed. This form will be kept in your personnel file.
The procedures for post-exposure cases are:




Document the route(s) of exposure and the circumstances under which the exposure incident
occurred.
Conduct a post exposure incident meeting.
Evaluate the operations to determine what engineering controls can be applied.
Evaluate and follow up with the exposed employee.
Apart from the circumstances surrounding the exposure itself, all other findings or diagnosis by the health care
professional(s) will remain entirely confidential
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