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Exposure Control Plan Template

1 Date

Date of this Exposure Control Plan: November 1998

2 Scope

This document is the written Exposure Control Plan for Northwestern University as required by the OSHA Occupational Exposure to Bloodborne Pathogens standard.

3 Universal Precautions

3.1 Definition

Universal precautions is an approach to infection control in which all human blood and other potentially infectious materials are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens (see appendix 4 for more examples of bloodborne pathogens).

Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. When it is difficult or impossible to differentiate between fluid types, universal precautions shall be observed.

4 Engineering and Work Practice Controls

4.1 Definitions

Engineering controls are controls that isolate or remove the bloodborne pathogens hazard from the workplace. Examples are sharps containers and self-sheathing needles.

Work practice controls are controls that reduce the likelihood of exposure by altering the manner in which a task is performed. If there remains a likelihood of occupational exposure even when engineering and work practice controls are in place, then personal protective clothing shall also be used.

4.2 Controls to be Used

4.2.1 Handwashing

Readily accessible handwashing facilities shall be provided, or, if this is not feasible, an appropriate antiseptic hand cleanser and clean cloth or paper towels. In any case, employees shall wash hands with soap and running water as soon as feasible after removal of gloves or other personal protective equipment.

The principal investigator or supervisor shall ensure that employees wash hands immediately or as soon as feasible after removing gloves or other personal protective equipment and also shall ensure that employees wash hands and any other skin with soap and water or flush mucous membranes with water immediately, or as soon as feasible, following contact of such body areas with potentially infectious materials.

4.2.2 Needles and Sharps

Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except as noted below. Shearing or breaking of contaminated needles is prohibited.

Contaminated needles and sharps shall be recapped or removed only when no alternative is feasible or when it is required by a specific medical procedure. Any recapping or removal must be accomplished through the use of a mechanical device or a one-handed technique. The recapping or removal of contaminated sharps is actively discouraged under any circumstances because of the high potential risk of injection.

Immediately after use, contaminated sharps shall be placed in sharps containers that are puncture-resistant, labeled or color-coded, and leakproof.

4.2.3 Eating, Drinking, Smoking, etc.

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets, or on countertops or benchtops where blood or other potentially infectious materials are present.

4.2.4 Splashing, Spraying, Spattering

All procedures involving blood or other potentially infectious materials shall be performed so as to minimize splashing, spraying, spattering, and generation of droplets.

4.2.5 Mouth Pipetting

Mouth pipetting of blood or other potentially infectious materials is prohibited.

4.2.6 Specimen Containers

Specimens of blood or other potentially infectious materials shall be placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping. Secondary containers are used when the outside of the primary container may be contaminated and when puncture of the primary container is possible. Storage, transport, or shipping containers are closed and labeled; the label should include the biohazard symbol. Color-coded containers should be red or orange.

4.2.7 Potentially Contaminated Equipment

Any equipment to be serviced or shipped that may be contaminated shall be examined prior to servicing or shipping and shall be decontaminated as necessary. If decontamination is not feasible, then the equipment shall be clearly labeled as to which portions remain contaminated. The laboratory is obligated to clearly communicate this information to employees, service personnel, and manufacturers as appropriate.

4.2.8 Other Engineering Controls

Other engineering controls include biological safety cabinets and chemical fume hoods. Engineering controls shall be examined and maintained on a regular schedule.

Chemical fume hoods used for containment of potentially infectious material are inspected by ORS according to a regular schedule. Facilities Management inspects and maintains chemical fume hood fan and duct systems.

The principal investigator or supervisor is required to ensure that biological safety cabinets used to protect workers from hazardous biological agents shall be tested and certified after installation, whenever they are moved, and annually. Certification shall be in accordance with National Sanitation Foundation Standard Number 49.

5 Personal Protective Equipment

5.1 Responsibility

The principal investigator or supervisor shall provide or ensure provision of appropriate personal protective equipment to each employee who is subject to occupational exposure to human blood or potentially infectious material. The equipment is provided at no cost to the employee. Examples of such equipment include gloves, gowns, laboratory coats, head and foot coverings, face shields, masks, eye protection, resuscitation bags, pocket masks, or other ventilation devices.

The principal investigator or supervisor shall ensure that each employee uses personal protective equipment when warranted.

Each principal investigator in charge of a laboratory with employees covered under the Bloodborne Pathogens Standard shall complete a Safety Plan that documents the use of personal protective clothing and equipment in detail.

5.2 Availability

Protective equipment in appropriate sizes shall be available in the work area or issued to employees. Hypoallergenic gloves or similar alternatives shall be readily available to those allergic to the normal gloves provided.

5.3 Cleaning and Repair

The principal investigator or supervisor shall ensure that personal protective equipment shall be cleaned, laundered, or disposed of at no cost to the employee. Personal protective equipment shall be repaired or replaced as needed to maintain its effectiveness.

5.4 Wear in Work Areas Only

All personal protective equipment shall be removed prior to leaving the work area.

5.5 Gloves

Gloves shall be worn when it is reasonably anticipated that employees may have hand contact with blood, other potentially infectious materials, mucous membranes, and nonintact skin. Gloves shall be worn when performing vascular access procedures and when handling or touching contaminated items or surfaces.

Disposable gloves shall be replaced as soon as practical when contaminated, torn, punctured, or otherwise compromised in their ability to function as a barrier.

Utility gloves (nondisposable gloves) may be decontaminated for reuse provided the integrity of the glove is not compromised. They must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration.

There are specific regulations related to phlebotomy. See the OSHA standard or contact ORS for details.

5.6 Masks, Eye Protection, and Face Shields

Masks in combination with eye protection devices (such as goggles or glasses with solid side shields) or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious material may be generated and eye, nose, or mouth contamination can be reasonably anticipated.

5.7 Gowns, Aprons, and Other Protective Body Clothing

Appropriate protective body clothing shall be worn in occupational exposure situations. When gross contamination can be anticipated, surgical caps or hoods and shoe covers should be worn.

6 Housekeeping

6.1 Responsibility

The principal investigator or supervisor is responsible for ensuring that the work area shall be maintained in a clean and sanitary condition. A written schedule for cleaning and method of decontamination is required.

6.2 Cleaning

All equipment and environmental and working surfaces shall be cleaned and decontaminated with an appropriate disinfectant after contact with blood or other potentially infectious material. Contaminated work surfaces shall be decontaminated after completion of procedures, immediately or as soon as feasible after any contamination of surfaces or after any spill of blood or other potentially infectious materials, and at the end of the work shift if the surface may have become contaminated since the last cleaning.

Protective coverings such as plastic-backed absorbent paper shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.

All bins, pails, cans, and similar receptacles intended for reuse that have a reasonable likelihood of becoming contaminated shall be inspected and decontaminated on a regularly scheduled basis. They shall be cleaned or decontaminated immediately or as soon as feasible if there is visible contamination.

Environmental surfaces (e.g., floors) are routinely cleaned either by Facilities Management personnel or by an outside contractor under the direction of Facilities Management. The schedule and method of implementation are presented in their departmental procedures.

NOTE: Facilities Management or Housekeeping do not clean contaminated floors. If floors are overtly contaminated or suspected of being contaminated, department personnel shall clean and decontaminate the floors using appropriate procedures.

The principal investigator or supervisor shall ensure routine cleaning of work surfaces and equipment as well as cleaning and disinfection of equipment, environmental surfaces, and work surfaces that have been in contact with human blood or other infectious materials.

Chemical disinfectants are summarized in the Biosafety Manual with their usage parameters, applications and the organisms for which they are effective. Any of the disinfectants listed are effective for bloodborne pathogens. Purchased disinfectants are recommended if their parameters meet those described.

6.3 Broken Glassware

Broken glassware that may be contaminated shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush or dustpan, a vacuum cleaner,tongs, or forceps.

7 Waste Disposal

7.1 Contaminated Sharps

Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are closable, puncture-resistant, leakproof, and labeled or color-coded. Sharps containers shall be easily accessible to employees and located close to the immediate area where sharps will be used. Sharps containers shall be kept upright throughout use, be replaced routinely, and not be allowed to be overfilled.

Before sharps containers are removed from the work area, they shall be closed securely. If leakage is possible, a closable, sturdy, leakproof, and labeled or color-coded secondary container shall be used.

Principal investigators or supervisors are responsible for ensuring that appropriate sharps containers and other biohazardous waste containers are made available and are used.

7.2 Other Biohazardous Wastes

Other waste containers that contain blood or other potentially infectious material shall be closable, able to contain all contents, leakproof, labeled and/or color-coded, and closed securely prior to removal. If the primary waste container is contaminated on the outside, a closable, sturdy, leakproof, and labeled or color-coded secondary container shall be used, and it shall also be closed prior to removal.

8 Laundry

8.1 Instructions

Contaminated laundry shall be handled as little as possible with a minimum of agitation. It shall be placed into bags or containers at the point of use. It shall not be sorted or rinsed in the location of use. The bags or containers shall be labeled with the biohazard symbol or color-coded (red/orange). The bag or container shall be constructed to prevent soak-through or leakage.

The principal investigator or supervisor shall ensure that employees who handle contaminated laundry shall wear protective gloves and other appropriate personal protective equipment.

Current University policy on the handling of contaminated laundry requires that it be autoclaved or disinfected prior to laundering. This enhances the protection of those individuals who have to handle the laundry after it leaves the laboratory and simplifies the laundry handling procedures in the facility which cleans it.

Contaminated sharps shall never be included with laundry. Contaminated laundry is never washed with an individual's personal belongings or sent to a laundry service not aware of the hazards.

9 Hepatitis B Vaccination and Postexposure Evaluation and Follow-up

9.1 Responsibility

The principal investigator or supervisor is responsible for making the hepatitis B vaccine and vaccination series available to all employees who have occupational exposure. Postexposure evaluation and follow-up shall be made available to all employees who have sustained an exposure incident. All laboratory tests shall be conducted by an accredited laboratory at no cost to the employee.

Vaccine, vaccination, and all medical evaluations and procedures:

  • shall be made available at no cost to the employee
  • shall be made available at a reasonable time and place
  • shall be performed by or under the supervision of a licensed physician or other licensed healthcare professional
  • shall be provided according to the recommendations of the U.S. Public Health Service at the time the evaluations and procedures take place, except as noted below

9.2 Hepatitis B Vaccination

Hepatitis B vaccination shall be made available. The vaccination shall be provided/scheduled after the employee has received the training required in the training section of this document, and within 10 working days of initial assignment to any employee who has occupational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons. Participation by the employee in a prescreening program shall not be a prerequisite for receiving hepatitis B vaccination.

An employee who accepts vaccination shall complete and sign the Consent/Waiver form.

An employee may decline vaccination but decide to accept it at a later date in accordance with Section 9.1 above. If an employee declines vaccination, the employee shall sign the statement also found in the Consent/Waiver form.

Any booster doses that may be recommended by the U.S. Public Health Service at a later date shall be made available in accordance with the vaccination requirements of this section.

The healthcare professional responsible for the employee's hepatitis B vaccination shall be provided with a copy of the OSHA Occupational Exposure to Bloodborne Pathogens Standard. The written opinion for hepatitis B vaccination shall depend on whether hepatitis B vaccination is indicated and if the employee has received the vaccination.

Acceptable methods of compliance with the vaccination requirement include in-house vaccination for departments having healthcare professionals on the staff and at the University Health Service (available to Evanston campus employees and to students on both campuses). Chicago campus employees should contact their supervisor for vaccination information. Contact ORS for information on recommended healthcare providers or healthcare providers with whom the University contracts to provide such services.

9.3 Postexposure Evaluation and Follow-up

9.3.1 Required Elements

Following a report of an exposure incident, the principal investigator or supervisor shall ensure that a confidential medical evaluation and follow-up are made available to the exposed employee. The evaluation shall include:

  • documentation of the route of exposure and the circumstances under which the exposure incident occurred
  • identification and documentation of the source individual unless it is not feasible or prohibited by law
  • collection and testing of the exposed employee's blood for HBV and HIV serological status
  • collection of an exposed employee's blood as soon as feasible and testing after consent is obtained: Testing may take place at a later date if the employee chooses, provided it is within 90 days of the exposure incident.
  • postexposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service
  • counseling
  • evaluation of reported illnesses

See Appendix 3 for procedures, or contact ORS for more information on where to obtain postexposure exams and follow-up care.

9.3.2 Notification Requirement

When an exposure incident occurs, notify the Claims Manager regarding workers' compensation if the exposed individual is an employee. All incidents shall be reported to ORS by using an Incident Report form for review by the Chemical and Biological Safety Committee. In keeping with the confidentiality requirement of the University AIDS policy, the names of persons involved in the incident and other identifying information may be omitted from the incident report.

9.3.3 Information Provided to the Healthcare Professional

The principal investigator or supervisor shall ensure that the following information is supplied to the evaluating healthcare professional. See Section 15 of the Bloodborne Pathogens Standard for the form to be used.

The information shall include:

  • a copy of the OSHA Occupational Exposure to Bloodborne Pathogens Standard
  • a description of the exposed employee's duties as they relate to the exposure incident
  • documentation of the route of exposure and circumstances under which the exposure occurred
  • results of the source individual's blood testing, if available
  • all medical records relevant to the appropriate treatment of the employee including vaccination status that the department head is responsible for maintaining.

9.3.4 Written Opinion Requirement

The principal investigator or supervisor is required to obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation.

The healthcare professional's written opinion shall be limited to whether hepatitis B vaccination is indicated for the employee and, if the individual has received such vaccination, a statement that the individual has been informed of the results of the evaluation and that the individual has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials that require further evaluation or treatment. All other findings or diagnoses shall remain confidential and shall not be included in the written report.

All laboratory tests shall be conducted by an accredited laboratory. The employer must be able to document (e.g., by certificate) that the laboratory is accredited by a national accrediting body (such as CDC or College of American Pathologists) or equivalent state agency that participates in a recognized quality assurance program.

9.4 Medical Records

An accurate medical record for each employee with occupational exposure is maintained. The record includes:

  • name and Social Security number of the employee
  • a copy of the employee's hepatitis B vaccination status, including the dates of all the hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination
  • a copy of all results of examinations, medical testing, and follow-up procedures
  • a copy of the healthcare professional's written opinion
  • a copy of the information provided to the healthcare professional

Employee medical records shall be kept confidential and shall not be disclosed or reported without the employee's express written consent to any person except as required by the OSHA standard and by law. If the employer has contracted with a clinic or other healthcare facility to provide the follow-up programs, the confidentiality requirements must be part of the contract.

When an exposure incident occurs, the results of the source individual's testing become a part of the confidential medical record and must be made available to the employee. Employees must be afforded unrestricted access to their medical records.

Employee medical records shall be maintained for at least the duration of employment plus 30 years.

10 Communication of Hazard to Employees: Labels

10.1 Labels

Warning labels are required on containers of biohazardous waste (unless the waste is placed into red/orange bags), refrigerators and freezers containing blood or other potentially infectious material, and other containers used to store, transport, or ship blood or other potentially infectious materials. The labels shall include the biohazard symbol and the word "biohazard." The principal investigator or supervisor shall ensure, either through inspection or delegation to supervisory staff, that appropriate labels are in place. Labels may be obtained from ORS.

11 Communication of Hazard to Employees: Information and Training

11.1 Responsibility

Principal investigators or supervisors are responsible for ensuring that all employees with occupational exposure participate in a training program, which must be provided during working hours at no cost to the employee.

11.2 Training Program Available

ORS maintains a training program that, when supplemented by site-specific information, can satisfy the training requirement of the standard. The course is offered both as an online and classroom course. Click here for more information.

The University Health Service employs health educators who can provide training to employees. Contact the Health Service for details, including fee information.

11.3 Schedule

Training shall be provided at the time of initial assignment to tasks where occupational exposure may take place and at least annually thereafter. Annual training shall be provided within one year of previous training.

11.4 Additional Training

Principal investigators or supervisors shall ensure that employees receive additional training when changes, such as modifications of tasks and procedures or institution of new tasks or procedures, affect the employee's occupational exposure.

11.5 Language, Literacy, and Educational Level

Training shall consist of material appropriate in content and vocabulary to the educational level, literacy, and language of employees. If an employee is proficient in a foreign language only, the trainer or an interpreter must convey the information in that language.

11.6 Content

As a minimum, the training program shall contain:

  • an accessible copy of the standard and an explanation of its contents
  • a general explanation of the epidemiology and symptoms of bloodborne diseases
  • an explanation of the modes of transmission of bloodborne pathogens
  • an explanation of the Exposure Control Plan and how to obtain a copy of the written plan
  • an explanation of how to recognize tasks and activities that may involve exposure to blood and other potentially infectious materials
  • an explanation of the use and limitations of methods that will prevent or reduce exposure, including appropriate engineering controls, work practices, and personal protective equipment
  • information on the types, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment
  • an explanation of the basis for the selection of personal protective equipment
  • information on the hepatitis B vaccine
  • information on appropriate actions to take and persons to contact in an emergency
  • an explanation of the procedure to follow if an exposure incident occurs
  • information on postexposure evaluation and follow-up
  • an explanation of the signs and labels and/or color coding
  • an opportunity for interactive questions and answers

Common bloodborne diseases other than HIV and HBV, such as hepatitis A and syphilis, must be described. Uncommon diseases do not need to be described in detail unless employees work with particular bloodborne pathogens.

11.7 Records

Training records shall be maintained by the principal investigator or supervisor and shall include the following information. Records shall include:

  • dates of training sessions
  • contents or summary of the training sessions
  • names and qualifications of persons conducting the training
  • names and job titles of all persons attending the training sessions

Training records shall be maintained for three years from the date on which the training occurred. Training records shall be provided on request for examination and copying to employees and to employee representatives.

11.8 Implementation

The principal investigator or supervisor shall ensure that all employees who are occupationally exposed receive training according to the requirements of the OSHA standard.

Training may be provided through the use of a combination of videotapes, handouts, pre- and post-tests, and personal presentations. Each training session shall include an opportunity for employees to ask questions. Training employees solely by means of a film or video is not permitted unless the required site-specific information is presented and a trainer is available to answer questions.

The person conducting the training is required to knowl the subject matter covered by the training program, including site-specific information. Possible trainers include a variety of healthcare professionals such as infection control practitioners, nurse practitioners, registered nurses, physician's assistants, or emergency medical technicians.

Non-healthcare professionals such as industrial hygienists, epidemiologists, or professional trainers may conduct the training provided they can demonstrate evidence of specialized training in the area of bloodborne pathogens.

12 First Aid Provision

First aid providers whose primary job is not first aid administration do not have to be offered pre-exposure hepatitis B vaccination, according to OSHA. If the so-called secondary first aid providers are exposed to human blood or other potentially infectious materials on the job, the vaccine must then be offered within 24 hours of the incident. In addition, appropriate postexposure evaluation, prophylaxis, and follow-up must be provided to employees who have an exposure incident.

If you have secondary first aid providers in your department, your written ECP must address this issue. It must include:

  • a reporting procedure for incidents
  • a list (a log) of first aid incidents
  • documentation of employee training in the specifics of the reporting procedure. Exposure incidents must be reported before the end of the same shift during which the exposure incident occurred.

Technically, the failure to offer pre-exposure hepatitis B vaccination is still a violation. As a matter of policy, OSHA considers it a de minimis violation and citations will not be issued.


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