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7-2: Bloodborne Pathogen Control Exposure

* Issued: 1-1-94
* Revised: 12-01


The Occupational Safety and Health Administration (OSHA) reports that 5.6 million employees in the United States are at risk of exposure to bloodborne pathogens where they work. This Bloodborne Pathogen (BBP) Exposure Control Policy is designed to protect Fort Lewis College employees. This plan includes the following key elements:

A. Identification of Job Classifications and tasks where there is exposure to blood and other potentially infectious materials.

B. Methods of Compliance Such as:

-Universal precautions,
-Engineering and work practice controls,
-Personal protective equipment,

C. Training of Employees.

D. Hepatitis B Prevention.

E. Post-Exposure Evaluation.

F. Procedures for evaluating the circumstances of an exposure incident.

G. It will be the responsibility of the Fort Lewis College Health Center to administer this policy with the advisement of the office of Human Resources and with the assistance of the safety committee and safety coordinator.

The Fort Lewis College BBP Exposure Control Policy must be accessible to all employees and also be updated at least annually, and when alterations in work practices create new occupational exposure.

II. Exposure Determination - Job Classification:

Occupational exposure is defined by OSHA as those individuals who can "reasonably anticipate skin, eye, mucous membrane or parenteral exposure to blood or other potentially infectious materials that may result from the performance of an employee's duties." It is the employer's responsibility to determine which job classifications and which specific tasks and procedures involve occupational exposure. If the employer determines that there is a blood exposure problem, even though the employees are in a non-health care setting, proper procedures and precautions should be applied.

Fort Lewis College has performed an exposure determination for employees who may incur occupational exposure to blood or other potentially infectious materials. This determination was made without regard to the use of personal protective equipment. All Fort Lewis College employees will fall into one of three job classification categories as related to BBP exposure. The specific job classifications and the requirements of each category follows:

A. Job classifications in which all employees in those classifications have occupational exposure:

Health Center Physician Assistant
Health Center Registered Nurse and Licensed Practical Nurse
Campus Police
Athletic Trainer
Student Athletic Trainer

The above job classifications will have mandatory bloodborne pathogen (BBP) training within 10 days of employment and on an annual basis. Hepatitis B immunization will be offered to a new employee within 10 days of employment on a mandatory with right to waiver basis. There will be no cost to the employee for these services. If the employee has waived the immunization requirement and has an exposure to a BBP, immunization must be offered within 24 hours.

B. Job classifications in which some employees may have occupational exposure:

Conference Services Utility Crew
Physical Plant, College Union Building, and Residential Life Custodians
Health Center Administrative Assistant
Residential Life Directors, Resident Assistants, and Assistant Directors
Lab Instructors (including student lab instructors)
Outdoor Pursuits Director and Assistant Director
Athletic Equipment Manager and Assistant Manager
Swimming Pool Lifeguards and Certified Pool Operator
Intramural Open Recreation supervisors
Child Development Center Employees and Child Development Student Workers
Student Life Center Director, Assistant Director, and Student Life Center Employees

Even though student instructors/workers are not employees, they will be covered under this policy if they have potential for exposure to bloodborne pathogens with the department they are working. On the first day of service, if there is potential for the student to be exposed, the student will be instructed by the department director on the proper use of gloves. Then the student will receive the complete BBP training later.

The above job classifications will have mandatory BBP training within 30 days of employment. It will be at the discretion of department chairs as to whether the training will be provided on an annual basis. Hepatitis B immunization will be offered to the new employee within 10 days with a right to waiver. There will be no cost for these services. If the employee has waived the immunization offering initially and has an exposure to a BBP, post-exposure care must be offered within 24 hours.

C. All Other Fort Lewis College Job Classifications - Training will be made available, but not required. It will be at the discretion of the department directors to make training mandatory, either one time or annually, for their department. The College will not pay for Hepatitis B immunization.

The Health Center will offer this immunization to these employees at the low cost that it charges students. If any employee of this group has an exposure to a BBP, they should go through the regular Workers Compensation process as outlined in section VI. In the event of an exposure to BBP incident, Hepatitis B immunization must be started within 24 hours if there has been no prior immunization and must be provided at no cost to the employee.

D. Tasks Where There May be Possible Exposure to BBP

1. Medical tasks- phlebotomy, minor surgery, dressing wounds, performing laboratory testing, handling regulated waste.

2. Emptying trash, cleaning rest rooms.

3. Working on sewer lines.

4. Cleaning spills of body fluids.

5. Administering first aid.


Fort Lewis College will offer training on BBP to its employees. Some employees are to receive free training at the time of initial employment and annually as described in Section II - Job Classifications. The instructor is required to be knowledgeable in the subject matter, preferably being a health care provider.

A. Training Requirements - The employer is required to provide training to certain at risk employees at the time of initial assignment to tasks where occupational exposure may occur and the training should be repeated annually. (See Section II - Job Classifications.) Training will be tailored to the education and language level of the employees, and offered during normal work hours. The training is to be interactive and include:

- An explanation of the OSHA standard.

- A discussion of the epidemiology and symptoms of bloodborne diseases.

- An explanation of the modes of transmission of blood-borne pathogens.

- An explanation of the Fort Lewis College BBP Exposure Control Policy, and how employees can obtain a copy.

- The recognition of tasks which may involve exposure, explanation of their use and limitations of methods to reduce exposure. These include engineering controls, work practices, and personal protective equipment (PPE).

- Information on the types, use, location, handling, decontamination and disposal of PPE.

- An explanation of the basis of selection of PPE.

- Information on the hepatitis B vaccination to include efficacy, safety, method of administration, benefits and that it will be offered free of charge to certain designated job classifications.

- An explanation of the procedures to follow if an exposure incident occurs, including the method of reporting and medical follow up.

- An explanation of the signs, labels, and color-coding systems used by the organization.

B. Training Record Information - Employee training records shall be maintained for three years from the date of training. These records shall include the following:

- The dates of the training sessions.

- An outline describing the materials presented.

- The names and qualifications of persons conducting the sessions.

- The names and job titles of all persons attending the training sessions and signature of the employee .

All employee records will be made available to OSHA or the National Institute for Occupational Safety and Health (NIOSH) or the employee upon request.

The Fort Lewis College Health Center will be responsible for maintaining training records for those job classifications where training is required. The new employee will be notified that training is required at the time of employee orientation. The Office of Human Resources will notify the trainer of all new employees.

The Fort Lewis College Bloodborne Pathogen Exposure Control Trainer, will be responsible for an annual review of the training program, updating it as necessary.


A. Universal precautions will be observed at this facility to prevent contact with blood and other potentially infectious materials. Where it is difficult to differentiate between body fluid types, all such body fluids shall be considered potentially infectious materials.

B. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine and vomitus unless they contain visible blood. The risk of transmission of HIV and HBV from these fluids and materials is extremely low or nonexistent. However, some of the above fluids and excretions represent a potential source of acquired infections with other pathogens, and recommendations for preventing the transmission of non-bloodborne pathogens would be to use universal precautions.

C. Personal Protective Equipment (PPE) - Universal precautions require that PPE be used where exposure to BBP is possible. Each department is responsible for ensuring that the following provisions are met:

1. Individual departments within Fort Lewis College for which an employee works will supply PPE to employees which is appropriate to their reasonably anticipated blood or potentially infectious materials exposure. PPE will be provided free of cost to employees.

2. It will be mandatory that each of our employees use the appropriate PPE in areas where exposure to bloodborne pathogens might occur.

3. Each of our employees will be issued PPE which is properly fitted. Disposal of contaminated PPE will be provided to the employees free of cost. Examples of PPE are safety glasses, face shields and gloves.

4. Before leaving the work area, employees shall remove all PPE and place it in a designated container for storage, washing, decontamination, or disposal as appropriate to the work area.

5. Gloves shall be worn where it is reasonably anticipated that employees may have hand contact with blood or other potentially infectious materials and when handling or touching contaminated items or surfaces. If hands are cut or scratched, double gloves should be worn or heavy duty latex gloves if they are available.

6. Disposable gloves used at this facility shall not be washed or re-used after contamination. Disposable gloves shall be replaced as soon as their protective ability is compromised, such as being torn or punctured.

7. Utility gloves shall be used for handling contaminated waste and for clean-up procedures at this facility. Utility gloves shall be washed and decontaminated for re-use, unless they are cracking, peeling, or are otherwise compromised.

8. For any employee who has allergic sensitivity, Fort Lewis College will provide hypo-allergenic gloves, or powderless gloves, free of charge.

C. Housekeeping, Engineering and Workplace Controls

1. Handwashing facilities with antiseptic soap or single use antiseptic towelettes will be provided for immediate use after contamination.

2. Employees will wash hands immediately after removing gloves.

3. Eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses is prohibited in our work areas where exposure to BBP is possible.

4. Any equipment, laboratory samples, laundry, et cetera, will be examined before leaving the facility to be sure it is not contaminated.

5. Labels and other warnings, as specified in 1910.1030(g), will be affixed to contaminated materials to warn others. The Health Center and athletic training center will ensure that the Hazardous Waste containers within their departments will be properly labeled.

6. Contaminated medical waste will be handled in the following manner:

a) The Health Center and the Athletic Training Room will place medical waste into appropriately marked medical waste storage containers. The health center will contract with a medical waste disposal company to dispose of waste.

b) In all other areas of campus, when there is to be a clean up of infectious waste material the following procedure should be followed:

1. Put on gloves and other protective equipment as necessary. Post wet floor signs if available.

2. Apply a tuberculocidal disinfectant over the potentially infectious material in accordance with label directed use.

3. Clean-up contaminated material with disposable paper towels and place in a plastic bag and dispose of in the trash.

4. Apply the disinfectant cleaner to the contaminated spot and continue cleaning the remainder of the room if appropriate.

5. Remove gloves and if disposable, discard in the trash. Wash hands thoroughly.

6. If a "Mess Kit" is used, follow the instructions on the package.

D. These Compliance (Prevention) Methods will be reviewed every 12 months by the safety committee and updated as new information becomes available and/or when new employee positions with the potential for exposure are created.


This section addresses the procedures which are implemented to meet the minimum OSHA standards in reference to Hepatitis B Vaccination. The policy implemented in this section provides a means to protect employees at Fort Lewis College from infection caused by Hepatitis B. The Hepatitis B vaccination refers to the Hepatitis B vaccine and vaccination series.

Fort Lewis College has determined that some of its employees have occupational exposure to bloodbornepathogens. A list of these employees listed by job classification is found in Section II of this exposure control plan. The following are available to all of these exposed employees:

A. All required services will be provided to the employee at no cost to the employee. The employee should receive these services at the Fort Lewis College Health Center. The following will be performed by or under a licensed physician or another licensed healthcare professional and all laboratory tests are to be conducted by an accredited laboratory.

B. The Hepatitis vaccination will be available to occupationally-exposed employees preferably after receiving proper training on information relating to the Hepatitis B vaccine, including information on its safety, efficacy, method of administration, benefits of vaccination and that the services will be provided free of cost.

C. The Hepatitis B vaccine will be made available within 10 working days of the initial assignment regardless of which training has been received. The office of Human Resources will notify the Health Center weekly by E-mail of all new employees. If the employee has not been to a training session, the Health Center nurse should explain about the vaccine before administration. There are four exceptions:

1. The employee previously received the complete Hepatitis B series.

2. Antibody testing has revealed that the employee is immune. Employees have the right to request an antibody titre to check for immunity at no charge prior to starting the vaccination series.

3. The vaccine is contraindicated for medical reasons.

4. The employee declined the vaccine. In this case, if the employee initially declines Hepatitis B vaccination but at a later date, still covered under the standard, decides to accept the vaccination, it will be provided to the employee at that time.

If Exception 1., 2., or 3., is pertinent to a particular employeeâ¿¿s case, documentation for applicability of the exception must be obtained and included in the employeeâ¿¿s confidential medical file.

If the employee declines the vaccine (Exception 4.), the employee must sign the Hepatitis B declination Form. Once completed, this form should be included in the confidential medical file kept at the Fort Lewis College Health Center.

Participation in a prescreening program will not be a prerequisite for receiving Hepatitis B vaccination.

The term "no cost to the employee" means no out of pocket expense to the employee. The employee will not be required to use his/her insurance to pay for the series unless the entire cost of health insurance is paid by the employer and unless there is no cost to the employee in the form of deductibles, co-payments or other expenses.

The employer is prohibited from instituting a program in which the employee pays the original cost of the vaccine and is reimbursed if the employee remains employed for a specific period of time. An "amortization contract" which requires the employee to reimburse the employer for the cost of the vaccine, should the employee leave the employment prior to a specified time, is also prohibited.

If a routine booster dose(s) of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, booster will be made available to all employees in the same manner as described above for Hepatitis B vaccination.


If employees follow the prevention guidelines as presented in this text, an exposure incident to a BBP should be a rare event. However, if the employee does have an exposure incident it shall be reported , investigated and documented. Employees who have been exposed to BBP shall report the incident through normal Workers Compensation procedures; first the supervisor, then Human Resources, and then to the Urgent Care Center at Mercy Medical Center. Since it is imperative that medical attention be sought promptly, the employee is permitted to go to the Urgent Care Center at Mercy Medical Center before going to the supervisor or to the office of Human Resources.

If the incident occurs when the Human Resources office is closed, then the employee should first attempt to notify the supervisor; then the employee is to go to the Urgent Care Center (located by the Emergency room) at Mercy Medical Center. Cost for these services will be covered by Workers Compensation. The employee needs to be sure to inform the registration desk that they are from Fort Lewis College and that the employees' services at the Urgent Care Center will be covered by Workers Compensation. It is very important that an employee with a Bloodborne Pathogen exposure be seen the day of the incident.

Following an employee report of a possible exposure incident, the employer must:

- Immediately make available to the employee a confidential medical evaluation by a designated Health Care Professional.

- Prepare a confidential comprehensive follow up reporting the exposure incident.

(See Attached pages 8-1 - 8-14.)

These guidelines from the Fort Lewis College Health Center Exposure Control Plan will be adopted as the in depth guide to handling a BBP exposure incident.


A. Sanitary Napkin Disposal - OSHA considers the disposal of sanitary napkins an effective engineering control against exposure to blood. Sanitary napkins do not require biohazardous labeling or disposal. PPS will provide and demand that gloves be worn when handling trash, and waste bags should be kept away from the body.

OSHA does not generally consider discarded feminine hygiene products, used to absorb menstrual flow, to fall within the definition of regulated waste. The intended function of products such as sanitary napkins is to absorb and contain blood; the absorbent material of which they are composed would, under most circumstances, prevent the release of blood.

OSHA expects the waste containers into which these products are discarded to be lined with a plastic or wax paper bag. Such bags should protect the employee from physical contact with the contents. If the inspection of a sanitary napkin disposal container carries visible signs of soil, the entire dispenser should be cleaned with an appropriate disinfectant product.

Bloodborne Pathogen Post-Exposure Form

Hepatitis B Vaccine Declaration Form

Training Record Form