Bloodborne Pathogens Exposure Control Plan - Oakland University

Oakland University 

Bloodborne Pathogens 

Exposure Control Plan 

MAY 1992 

(Revised 1993, 1994, 1996, 1999, 2000, 2001 and 2004) 

Office of Environmental Health and Safety 

Department of Risk Management and Contracting 

Rochester, Michigan 48309-4401 

(248) 370-4196


Bloodborne Pathogens 

Exposure Control Plan 

for 

DEPARTMENT: ___________________________ 

MAY 1992 

[Revised 1993, 1994, 1996, 1997, 2000 and 2001] 

Office of Environmental Health and Safety 

Graham Health Center 

(248) 370-4196


Bloodborne Pathogens Exposure Control Plan 

TABLE OF CONTENTS 

1.0 About this Written Exposure Control Plan................................................................................. 1 

1.1 The Written Exposure Control Plan Includes ........................................................ 1 

2.0 Program Administration............................................................................................................... 2 

TABLE 1 - Individuals Responsible for Implementing the ECP in their Departments. ................. 3 

3.0 Employee Exposure Determination.............................................................................................. 4 

TABLE 2 - Job Classifications for which ALL employees Risk Occupational Exposure.............. 4 

TABLE 3 - Job Classifications for which SOME employees Risk Occupational Exposure........... 5 

4.0 Methods of Controlling Exposure to BBPs.................................................................................. 5 

4.1 Universal Precautions ............................................................................................ 5 

4.2 Work Practice Controls.......................................................................................... 5 

4.3 Engineering Controls ............................................................................................. 5 

TABLE 4 - Tasks Which May Present BBP Exposure and Associated PPE/Engineering Ctrls..... 6 

5.0 Biohazardous Waste ...................................................................................................................... 9 

5.1 Contaminated Sharps ............................................................................................. 9 

5.2 Contaminated Laundry .......................................................................................... 9 

5.3 Biohazard bags, hampers and sharp safes.............................................................. 9 

6.0 Contaminated Equipment........................................................................................................... 10 

7.0 Cleaning Up Spills........................................................................................................................ 10 

7.1 Washable Surfaces............................................................................................... 10 

7.2 Non-Washable Surfaces....................................................................................... 10 

8.0 Hepatitis B Vaccinations ............................................................................................................. 12 

8.1 “Pre-Exposure” Vaccinations .............................................................................. 10 

8.2 “Post-Exposure” Vaccinations............................................................................. 11 

9.0 Exposure Incident Response and Follow-up ............................................................................. 13 

9.1 Exposure Incident - First Response ..................................................................... 13 

9.2 Post-Exposure Evaluation and Follow-up ........................................................... 13 

10.0 Employee Training....................................................................................................................... 12 

10.1 When and How Often .......................................................................................... 12 

10.2 Who Conducts Training....................................................................................... 12 

10.3 Elements of Training ........................................................................................... 13 

11.0. Record Keeping............................................................................................................................ 13 

11.1 Training Records.................................................................................................. 13 

11.2 Medical Records .................................................................................................. 13 

11.3 Exposure Incident Evaluation Records................................................................ 14 

12.0 Conditions for Laboratories Working with HIV and Hepatitis Viruses ................................ 14 

12.1 Working in HIV and Hepatitis Viruses “Production Facilities” .......................... 14 

12.2 Working in HIV and Hepatitis Virus “Research Laboratories”........................... 15 

APPENDICES........................................................................................................................................... 21 

Blank Forms 

Completed Departmental Forms 

Universal Precautions and OSHA Bloodborne Pathogens Standard 

Oakland University BBP ECP Revised April 2004

1.0 ABOUT THIS WRITTEN EXPOSURE CONTROL PLAN 

This Exposure Control Plan is intended to serve as OU’s guide to the OSHA Standard 

1910.1030, “Occupational Exposure to Bloodborne Pathogens”, which requires, as a central 

component, the development and issuance of an Exposure Control Plan (ECP). 

The information contained in this publication is not considered a substitute for the OSH Act or 

any provisions of OSHA standards. It provides general guidance on the OSHA Bloodborne 

Pathogens Standard, but should not be considered the legal authority for compliance with OSHA 

requirements. Rather, the reader should consult the OSHA standard in its entirety and/or OU’s 

Office of Environmental Health and Safety (OEHS) for specific compliance requirements. 

1.1 The Written Exposure Control Plan includes: 

• Determination of employee exposure 

• Methods of controlling exposure, including: Universal Precautions and work practice controls 

• Engineering Controls and Personal Protective Equipment 

• Biohazardous Waste 

• Contaminated Equipment 

• Cleaning up Spills 

• Hepatitis B vaccination 

• Exposure Incident Response and Follow-up 

• Employee Training 

• Record keeping 

• Conditions for working with HIV or a Hepatitis virus in the laboratory 

Employees covered by the bloodborne pathogens standard receive an explanation of this ECP 

during their initial training sessions. It will also be reviewed in their annual refresher training. 

All employees have an opportunity to review this plan at any time during their work shifts by 

contacting the responsible persons identified in Table 1 (Section 2.0). If requested, those 

individuals will provide their employees with a copy of the ECP free of charge and within 15 

days of the request 

The responsible persons identified in Table 1 (Section 2.0) are responsible for reviewing the 

ECP annually, or more frequently if necessary, to identify 1) any new or modified tasks and 

procedures which affect occupational exposure and 2) any new or revised job classifications that 

present occupational exposure. 


2.0 PROGRAM ADMINISTRATION 

The individuals found in Table 1 below are currently responsible for the implementation of the 

ECP in their respective departments. These individuals are responsible to: 

• Maintain and provide all necessary personal protective equipment (PPE), engineering controls 

(e.g., sharps containers), labels, and red bags as required by the standard 

• Ensure that all medical actions required are performed and that appropriate employee health 

and OSHA records are maintained 

• Ensure that all training is provided and documented 

• Ensure that the written ECP is available to employees, OSHA, and NIOSH representatives; 

• Review the ECP (and request updates as necessary from the Office of EH&S) at least 

annually, and/or whenever necessary to include new or modified tasks and procedures. 

TABLE 1 

Individuals Responsible for Implementing ECP in their Departments 

Department Position(s) Employee Name(s) (as 

of Feb. 2005) 

Telephone 

Extension(s) 

Athletics 

Head Athletic Trainer 

Asst. Dir. Facilities & Ops 

Tom Ford 

Eric Stephan 

3189 

4050 

Biological Sciences Laboratory Manager Michael Poosch 3556 

Campus Cleaning Supervisors Herb Lucre, Wendy Tyrell 2168 

Campus Recreation 

Chemistry 

Asst. Dir., Campus Progs. 

Asst. Dir., Aquatics 

Assistant Laboratory 

Manager 

Mila Padgett 

Dan Plamondon 

4910 

4533 

Marcee Daly 2330 

Eye Research Institute Asst. to the Director Paulette Realy 2390 

Graham Health Center Coordinator Joanne Talarek 4375 

Grounds/Vehicle Maint. Supervisor Randy Drewry 2413 

Lab Animal Mgmt Svcs Manager Cliff Snitgen 4441 

Lowry Early Childhood Ctr Director Tiffany Wright 4100 

Meadow Brook Hall Facility Operations Manager Kim Zelinski 3140 

Electrical and Plumbing Foreman Dan Niezurawski 4438 

Oakland Center Asst. Director Operations Rich Zizek 3245 

Oakland University BBP ECP 

Page 2 of 19 

Revised April 2004

TABLE 1 

Individuals Responsible for Implementing ECP in their Departments 

Department Position(s) Employee Name(s) (as 

of Feb. 2005) 

Telephone 

Extension(s) 

Police Department Lieutenant Mel Gilroy 3339 

Residence Halls 

Custodial & Maintenance 

Mgrs 

Frank Moss 

Karen Pipitone 

4061 

3570 

School of Education Coor of Field Svcs. Sherrill Karppinen 3083 

School of Health Sci 

School of Nursing 

All Sci and Res Depts. 

Director Exercise Science 

Assoc. Professor, Exer Sci 

Assoc. Professor, Exer Sci 

Program Dir., Med Lab Sci 

Interim Associate Dean 

Nursing Laboratory Mgr 

Admin Project Coordinator 

Laboratory Compliance 

Manager (Office of EH&S) 

Brian Goslin 

Charles Marks 

Robert Jarski 

Lynne Williams 

Diane Norris 

Patricia Ketcham 

Joann Burrington 

4140 

4539 

4191 

4040 

4484 

4066 

4065 

Domenico Luongo 4314 

3.0 EMPLOYEE EXPOSURE DETERMINATION 

Table 2 below identifies those OU job classifications (i.e., positions) for which ALL employees 

who hold those positions risk occupational exposure to Bloodborne Pathogens (without regard to 

the use of personal protective clothing or equipment): 

TABLE 2 

Job Classifications for which ALL* employees Risk Occupational Exposure 

Clinical Faculty 

Coach 

Custodian 

Job Classification 

Equipment Room Attendant 

First Responder (Lifeguards, Facility 

Supervisors) 

Grounds keeper 


Athletics 


Campus Cleaning 

Meadow Brook Hall 

Oakland Center 


Athletics 


Athletics 


Grounds Maintenance 


Department(s) 


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Revised April 2004

TABLE 2 

Job Classifications for which ALL* employees Risk Occupational Exposure 


Department(s) 

Laboratory Compliance Manager (OEHS) 

Nursing Laboratory Manager 

Child Care Worker/Teacher 

Medical Assistant 

Nurse Practitioner 

Nurse, Registered 

Phlebotomist/Venipuncturist 

Physician 

Plumber 

Police Officer 

Student Intern 

Trainer 

Vehicle Maintenance Personnel 

All Sci and Res Depts. 


Lowry Child Care Center 


School of Health Sciences (Med Lab Sci and Exer Sci) 


Mechanical Maintenance 


Police Department 

Health Sciences (Med Lab and Exercise Sciences) 

School of Education 


Athletics 


Grounds Maintenance Department 

* regardless of whether part- or full-time, permanent or temporary 

Table 3 below identifies those OU job classifications for which SOME employees who hold 

those positions risk occupational exposure to Bloodborne Pathogens (and some may not), 

without regard to the use of personal protective clothing and equipment: 

TABLE 3 

Job Classifications for Which SOME Employees Risk Occupational Exposure 


Department 

Directors, Managers and Supervisors All Departments listed in Table 1 (Section 2.0) 

“Laboratory” Personnel 

[Includes Faculty, Instructors (adjunct, 

associate, part-time, temporary or visiting), Lab 

Technicians, Researchers, Research Assistants, 

Research Technicians, PIs, Graduate Assistants, 

and Graduate Students] 

Biological Sciences 

Chemistry 

Eye Research Institute 

Health Sciences (Med Lab Sci and Exercise Sci) 

Laboratory Animal Management Services 

Student Employees 

Athletics 



All laboratory sciences listed in box above 


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Revised April 2004

4.0 METHODS OF CONTROLLING EXPOSURE TO BBPS 

4.1 Universal Precautions: All OU employees will utilize “Universal Precautions”: 

guidelines developed by the Center for Disease Control wherein all human blood or other 

potentially infectious body fluids are treated as if known to be infectious. A copy of 

these Universal Precautions is included in the Appendices of this document. 

4.2 Work Practice Controls: In addition to personal protective equipment and engineering 

controls, “work practice controls” will be used to prevent or minimize exposure to 

bloodborne pathogens. These include the following: 

• Following tasks which present exposure to BBPs, hands are always washed with soap 

and water immediately after removing personal protective equipment. 

• Following an “exposure incident” (i.e., unprotected skin or mucous membrane 

contact with human blood or other potentially infectious materials, OPIM), the 

exposed area is washed with soap and water (or, in the case eyes, flushed with an 

eyewash) for 15 minutes. 

• Contaminated needles are never recapped, but are placed instantly into sharps safes 

• Eating, drinking, smoking, applying cosmetics or lip balm, and/or handling contact 

lenses are prohibited in work areas where there is a reasonable likelihood of 

occupational exposure. 

• Food and drink shall never be kept in/on refrigerators, freezers, shelves, cabinets, 

counter-tops or benches where human blood or other OPIM are present. 

• All procedures involving blood or OPIM shall be performed in a manner as to 

minimize splashing, spraying, splattering, and generation of droplets. 

• Mouth pipetting/suctioning of blood or OPIM is prohibited. 

4.3 Engineering Controls 

4.3.1 Regulatory Overview: As of the April 18, 2001 amendments to the OSHA Bloodborne 

Pathogens Standard (revised in conformance with the requirements of the “Needlestick 

Safety and Prevention Act”), the term “Engineering controls” is defined as those 

“appropriate, commercially available, and effective controls which isolate or remove the 

bloodborne pathogens hazard from the workplace”. Examples provided in the Standard 

include the following: 1) devices designed to reduce the risk of percutaneous exposure to 

bloodborne pathogens, such as blunt suture needles and plastic or mylar-wrapped glass 

capillary tubes; 2) safer medical devices such as sharps with engineered sharps injury 

protection or needleless systems; and 3) approved sharps disposal containers. 

These amendments further require OU to solicit input its employees responsible for 

direct patient care in the identification, evaluation, and selection of engineering (and 

work practice) controls; annually update its BBP Exposure Control Plan to reflect the 

university has implemented any/all new developments in control technology; and 

establish and maintain a log of injuries from contaminated sharps (two types of log 

found in the Appendices of this document). 

4.3.2 Engineering and Personal Protective Controls used at OU: In accordance with the 

(original and more recent) engineering control requirements of the BBP Standard, and 

following several months of soliciting input from OU health care and lab research 

employees regarding selection of engineering controls, Table 4 below documents the 

specific tasks that present occupational exposure to BBPs on campus, and the associated 

engineering controls and personal protective equipment used in each unit on campus. 


Page 5 of 19 

Revised April 2004

TABLE 4 

Tasks which May Present BBP Exposure and the PPE/Engineering Used to Control 

(in alpha order by dept.) 

Department 

Tasks Which May Present 

Occupational Exposure 

PPE and Engineering 

Controls Used 

Location of PPE and Engineering 

Controls 

Athletics 

First Aid, Lactate Testing, Uniform 

& towel handling/cleaning 

Sharps Safes, Gloves, Gggles, 

Biohaz bags/hampers. 

Training Room, Aquatic Operations 

Office, Equipment Room 

Biological Sciences 

Dissection of Human Eyes for 

Tissue Culture in 301 DHE, and 

Primary and SV40 Transformed 

Human Cells Lines used in Tissue 

Culture in 304B and 304C. 

Gloves, Masks, Goggles, 

Biohazard Bags and Hampers, 

Sharps Safes, Biohazard Signs 

(posted at entrances to labs), 

Biohazard Labels, Autoclave, 

and Lab coats 

Each and every laboratory that handles 

biohazardous agents contains these 

items (except for the autoclaves which 

are located centrally in 320 SEB and 

lab coats issued to employees) 

Campus Cleaning 

Restroom clean, trash removal, lab 

cleaning, GHC cleaning, cleaning 

up after injuries involving blood 

Gloves, Biohazard Bags/ 

Hampers, Goggles, and Sharps 

Safes 

Campus Cleaning Supervisors’ Office, 

GHC, and Custodial Carts 


First Aid, Lactate Testing, uniform 

& towel handling/cleaning, cleaning 

up after blood/OPIM incidents 

Gloves, Sharps Safes, 

Goggles, Biohazard 

Bags/Hampers 

Training Room, Aquatic Operations 

Office, Equipment Room 

Chemistry 

Purification of lymphocytes from 

blood of human volunteers in 208 

and 210 SEB. 

Gloves, Goggles, Sharps 

Safes, Gloved Laminar Flow 

Hood, Lab Coats, biohazard 

bags/boxes 

208 and 210 SEB (laminar flow hood 

in 210 SEB) 

Education, School of 

Student Interns assist with child 

injuries (e.g., first aid/CPR) 

As appropriate based on 

judgements of Host Facilities 

Host Facilities supply onsite 

Eye Research Institute 

Dissection of Human Eye Tissue 

and Culture in 427 DHE and 

Processing of Human Eye Tissue 

Cells in Room 419 DHE. 

Gloves, Goggles, Biosafety 

Cabinet, Biohazard 

Bags/Hampers, Biohazard 

Signs (posted at entrances to 

labs), Biohazard Labels 

Every laboratory that handles 

biohazardous agents contains these 

items 


Drawing Blood, Handling Lab 

Specimens (e.g., blood, urine, etc.), 

Minor Office Surgeries, Office 

Procedures, Cleaning exam/trt rms. 

“BD Eclipse” blood collection 

needles”, Gloves, Masks, 

Sharps Safes, Biohazard 

Bags/Hampers, Goggles, Lab 

Coats, Gowns 

Exam/Treatment Rooms 

Grounds Maintenance 

----------------------------- 

Vehicle Maintenance 

Litter Pick-up, Trash Container Bag 

Removal, Trash Removal/ 

-------------------------------------------- 

Cleaning vehicles contaminated 

with blood or OPIM 

Gloves and Hand-held litter 

tool, Biohazard Bags/Hampers 

------------------------------------- 

Gloves, goggles 

BGM Building 

Health Sciences - 

Exercise Science 

CPR/First Aid performed by Student 

Interns at Host Facilities; 

venipuncture and finger-sticks 

performed in rm 207 HHS or 

occasionally in the field 

Hosts deem appropriate PPE 

for interns; PPE for VeniPunc 

includes “BD Eclipse” blood 

collection needles, gloves, 

sharp safes, goggles, lab coats 

and biohaz bags/hampers 

Host Facilities supply PPE onsite for 

interns; on-site PPE for venipuncture 

located in Room 207 HHS, or taken to 

field sites where tasks are being 

performed 

Health Sciences - 

Medical Laboratory 

Sciences 

Phlebotomy Instruction, 

Hematology Instruction, Clinical 

Analysis (instructional purposes), 

Washing lab glassware, 

Venipuncture and Urinalysis 

“BD Eclipse” blood collection 

needles, Gloves, Wrap-around 

Goggles, Biohazard 

Bags/Hampers, Biohazard 

Labels, Lab coats 

Phlebotomy Classrooms and carts, 310 

HHS and 373 HHS, and Lab coats 

issued to employees 


Page 6 of 19 

Revised April 2004

Department 

TABLE 4 

Tasks which May Present BBP Exposure and the PPE/Engineering Used to Control 

(in alpha order by dept.) 

Tasks Which May Present 

Occupational Exposure 

PPE and Engineering 

Controls Used 

Location of PPE and Engineering 

Controls 

Laboratory Animal 

Management Services 

(LAMS) 

Assisting med personnel using 

sharps (including surgery), handling 

infectious animals 


Biohazard Bags and Hampers, 

Sharps Safes, Biohazard Signs 

(posted at entrances to labs), 

Biohazard Labels, Autoclave, 

Bleach/Ethanol (for wiping 

down BSC2), and Lab coats 

Biomedical Research Support Facility 

Lowry Early Childhood 

Center 

First Aid, CPR, cleaning up blood, 

injections, and bites. 

Gloves, CPR Masks, Goggles, 

Biohazard Bags & Hampers, 

and Sharps Safes. 

Kitchen and Custodial Closet 


Cleaning Restrooms, Emptying 

Trash, Groundskeeping 

Gloves, Goggles, Sharps 

Safes, Biohazard 

Bags/Hampers 

Telephone Supply Room at MBH 

Mechanical Maint 

Plumbing and pipefitting in high 

risk areas (e.g., & restrms and labs) 

Gloves, Goggles 

Police and Support Services Bldg 

Nursing, School of 

Clinical Instruct and Patient care at 

off-site health care facilities 

Provided by off-site facilities 

Off-site 

Oakland Center 

Restroom clean, trash removal, 

Cleaning up after injuries involving 

blood, Trash Compaction 


Bleach, Biohazard 

Bags/Hampers, Sharps Safes 

OC Maintenance Shop and each 

custodial cart (except for hampers 

which are maintained in Shop) 

Police Department 

Accident Investigation, Treating 

Injured Persons, Processing Injured 

Victims or Injured Suspects, Subject 

or Vehicle Searches, Crime Scene 

Investigations, Evidence Processing, 

CPR/First Aid, Apprehending 

Suspects in High Risk Grps who are 

Resisting Arrest, Delivering Babies, 

Crowd Control 


Biohazard Bags/Hampers, 

Sharps Safes, Biohazard 

Labels/Signs, CPR masks 

(with valves) 

Police Station and all Officer/Patrol 

Units have all of these items (except 

for biohazard labels and hampers, 

which are only located in the Station) 

Residence Halls Clean 

and Maintenance 

Trash Removal, Restroom Cleaning, 

Cleaning up after Injuries Involving 

Blood, Plumbing in high risk areas 

(e.g., & restrms and labs) 

Gloves, Biohazard Bags/ 

Hampers, Goggles, Sharps 

Safes 

Custodial Carts and assigned rooms 


Page 7 of 19 

Revised April 2004

4.3.3 Rules Governing Engineering Controls and Personal Protective Equipment 

4.3.3.1 Selection: These responsible persons listed in Table 1 (Section 2.0) are required to 

consult with their staffs to identify what engineering controls and personal protection 

equipment are necessary on an ongoing basis through employee communication, 

observation and annual EH&S training sessions. EH&S will also help to ensure effective 

implementation of these recommendations. 

4.3.3.2 Maintenance: Sharps disposal containers are inspected, maintained and replaced by the 

responsible persons identified in Table 1 (Section 2.0) as needed to prevent overfilling. 

4.3.3.3 Training: Training in the use of the appropriate PPE for the tasks or procedures 

employees will perform is provided by the responsible persons (or their designees) 

identified in Table 1 (Section 2.0). 

4.3.3.4 All employees using PPE are required to 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 the red biohazard bags available in each department 

• Wear appropriate gloves when it can be reasonably 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, or if their ability to function 

as a barrier is compromised 

• Utility gloves may be decontaminated for reuse if their integrity is not compromised; 

discard utility gloves if they are 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 a way as to avoid contact with the outer surface 

4.3.3.5 Exceptions to Use: If an employee decides against using personal protective equipment 

under rare and extraordinary circumstances (e.g., would have prevented delivery of health 

care or public safety services, or would have posed increased hazard to safety of 

employee), the employee is required to complete a PPE Use Exception Form (found in 

the Appendices of this document) and submit it to his/her supervisor. This form is then 

carefully reviewed by the employee, his/her supervisor, and the Office of EH&S to 

determine whether changes could be instituted to prevent such occurrences in the future. 


Page 8 of 19 

Revised April 2004

5.0 Biohazardous Waste 

5.1 Contaminated sharps are managed as follows: 

• Broken glassware which may be contaminated is picked up using mechanical means, 

such as a brush and dust pan. 

• All contaminated sharps are discarded immediately or as soon as possible into “Sharps 

Safes”, which are available in the locations identified in Table 4 (of this Section 5.0). 

5.2 Contaminated laundry is managed as follows: 

• Sent out to those laundry facilities in the area willing and able to handle Biohazardous 

laundry. The Graham Health Center or EH&S can provide the name(s) of current 

facilities who perform this function. 

• Placed in leak-proof, labeled or color-coded containers before transport. Biohazard 

bags and hampers are available in the locations identified in Table 4. 

• Handled as little as possible by OU employees, and never taken home for laundering. 

5.3 Biohazard Bags, Hampers and Sharps Safes containing biohazardous waste are... 

• Maintained upright at all times 

• Replaced routinely and not overfilled, and 

• Closed prior to removal to prevent spillage or protrusion of contents during handling 

• Transported to the Office of EH&S when full as follows: 

o An "OU Medical Waste Internal Tracking Form" (Print Shop - order 

#001623) shall be completed for each "drop-off" (regardless of the number of 

containers), and brought (with the waste) to the Office of Environmental 

Health and Safety, in the Graham Health Center. 

o An individual from the Office of Environmental Health and Safety will review 

the manifest, keep two copies, and issue the bearer a key to the Phoenix Cage 

(located in the basement of the Graham Health Center). 

o At the time of drop-off, departments may also pick up empty biohazard 

hampers and/or bags from the Phoenix Cage as needed. The Biohazard 

hampers and bags are available at no charge; sharp safes can be ordered from 

most custodial/safety suppliers. 

o Once every two weeks, Stericycycle® shall remove the hampers/sharp safes 

from the Phoenix Cage, and transport them first to the BFI Medical Treatment 

Center in Toledo, Ohio (for high-temperature decontamination), and then to 

the Vienna Junction Sanitary Landfill, in Erie Michigan, for land disposal as 

non-hazardous waste. 


Page 9 of 19 

Revised April 2004

6.0 CONTAMINATED EQUIPMENT 

Responsible persons identified in Table 1 (Section 2.0) will ensure warning labels are affixed to, 

or red bags are used for, all biohazardous waste and/or contaminated equipment. If labels are 

not available in the department, the responsible person may contact the Office of Environmental 

Health and Safety for assistance in obtaining one. 

Employees are to notify their supervisors and/or the Office of Environmental Health and Safety 

if they discover regulated waste containers, refrigerators containing blood or OPIM, 

contaminated equipment, etc. without proper biohazard labels. 

7.0 CLEANING UP SPILLS 

7.1 Washable Surfaces: Contaminated equipment, floors, surrounding surfaces etc. shall be 

cleaned up (in such a manner that spreading, splashing, etc. the material is prevented) 

while wearing gloves and goggles, and using a ratio of ¼⎟2½ cups of bleach for every 1 

gallon of water, allowing10 minutes for disinfection to occur; after which any/all 

contaminated waste is placed in the proper biohazard receptacles. Broken glassware 

must be picked up using mechanical devices ONLY such as brush/dust pan, tongs, 

forceps, etc. 

7.2 Non-Washable Surfaces (e.g., carpets): Sanitary absorbent agents shall be used (e.g., 

“Zgoop”), let dry, and area vacuumed. Germicidal carpet shampoo is then applied and 

the area vacuumed again. Broken glassware must be picked up using mechanical devices 

ONLY such as brush/dust pan, tongs, forceps, etc. 

8.0 HEPATITIS B VACCINATION 

Included in new employee and annual refresher BBP exposure control training will be 

comprehensive information regarding hepatitis B vaccinations, including its safety, benefits, 

efficacy, methods of administration, and availability at no cost to the employees. Training in this 

regard includes, but is not limited to, the following information: 

8.1 Pre-Exposure Vaccinations: The hepatitis B vaccination series shall be made available 

at no cost to all “eligible” employees in Tables 2 and 3 (i.e.,those employees for whom 

exposure to BBPs is a primary function of their job descriptions ), after training and 

within 10 days of initial assignment. 

8.1.1 Contraindications to Vaccination: Vaccinations are encouraged unless: 

1) documentation exists that the employee has previously received the series, 2) antibody 

testing (i.e., a “titer”) reveals that the employee is immune, or 3) medical evaluation 

shows that the vaccination is contraindicated. 

8.1.2 Declining the Vaccination: If an employee chooses to decline vaccination, the 

employee must sign a “Hepatitis B Declination Form” (blank form found in the 

Appendices of this document). Employees who decline may request and obtain the 

vaccination at a later date at no cost to themselves (assuming their occupational 

responsibilities continue to present risk of exposure). Declination Forms are kept in the 

OEHS. Vaccinations are provided at OU’s Graham Health Center or the employee’s 

facility of choice. 


Page 10 of 19 

Revised April 2004

8.1.3 Health Care Professional Written Opinion: Prior to vaccination, the Health Care 

Professional shall provide a written opinion, indicating that (based on consultation) the 

employee presents no medical contra-indications to vaccination. 

8.2 Post-Exposure Vaccinations: For those employees for whom exposure to BBPs 

(generally via first-aid/CPR activities) is a collateral function of their job descriptions 

(e.g., coaches, trainers, day care professionals, etc.), the hepatitis B vaccination is not 

offered free of charge until AFTER these employees are involved in an incident where 

human blood or OPIM is present (regardless of whether an exposure incident occurred); 

these vaccinations are highly effective if administered within 1 to 7 days of the incident. 

9.0 EXPOSURE INCIDENT RESPONSE AND FOLLOW-UP 

9.1 Exposure incident - First Response 

Should an “exposure incident” occur (i.e., unprotected skin, eye or mucous membrane 

contact human blood or OPIM), the employee shall contact the responsible person 

identified in Table 1 (Section 2.0) from his/her department and/or the Officeof EH&S. 

Following IMMEDIATE first aid (cleaning the wound with soap and water, flushing eyes 

or other mucous membrane for 15 minutes), this person shall perform the following 

activities: 

• Ensure that employee goes to a hospital emergency room WITHIN 2 hours of the 

incident in order to obtain anti-viral drugs and baseline blood testing. NOTE: If the 

employee does not give consent for HIV serological testing during collection of blood 

for baseline testing, the baseline blood sample must be preserved for ∃ 90 days; if the 

exposed employee elects to have the baseline sample tested during this waiting 

period, testing shall be performed ASAP. 

• Ensure that, when it is convenient and reasonable, employee documents several 

pieces of critical information (preferably in time to show to treating physician), using 

OU’s Exposure Incident Report Form (found in the Appendices of this Document). 

This Exposure Incident Report Form requests the following information (and shall 

also be used by the Office of Environmental Health and Safety to evaluate the 

circumstances of the incident, generate ideas for prevention, modify the ECP, etc.): 

o engineering controls in use at the time 

o work practices followed 

o a description of the activity that preceded the exposure incident 

o protective equipment or clothing that was used at the time of the incident 

o location of the incident 

o procedure being performed when the incident occurred 

o route of exposure 

• Identify and document the source individual (unless the employer can establish that 

identification is infeasible or prohibited by state or local law). 


Page 11 of 19 

Revised April 2004

• Obtain consent (using a consent form found in the Appendices of this document) and 

make arrangements to have the source individual tested as soon as possible to 

determine HIV, HCV, and HBV infectivity; and document that the source individual's 

test results were conveyed to the employee's health care provider. 

• Ensure that the exposed employee is provided with the source individual's test results 

and with information about applicable disclosure laws and regulations concerning the 

identity and infectious status of the source individual (e.g., confidentiality laws). 

9.2 Post-Exposure Evaluation and Follow-up 

9.2.1 Supervisory Responsibilities: Responsible persons identified in Table 1 (Section 2.0) 

are required to ensure that any/all health care professionals responsible for follow-up care 

(following an exposure incident and initial testing/treatment) are provided: 

• A copy of the (completed) Exposure Incident Report Form; 

• A copy of OSHA’s Bloodborne Pathogens Standard; 

• Results of the source individual's blood test (when possible); and 

• Relevant employee medical records, including vaccination status. 

9.2.2 Written Opinions: The employee should then receive a copy of Health Care 

Professional(s) written opinion within 15 days after completion of the evaluation. 

9.2.3 Follow-up Care: Any/all follow-up testing, treatment, counseling, etc. shall be funded 

by Oakland University (department); employees shall bear none of the cost whatsoever. 

10.0 EMPLOYEE TRAINING 

10.1 When and How Often: All employees who have occupational exposure to bloodborne 

pathogens receive training before they conduct any activities which could pose exposure 

to BBPs, and annually thereafter. 

10.2 Who Conducts Training: BBP Exposure Control Training for new employees and 

annual refresher training is conducted by responsible persons identified in Table 1 

(Section 2.0) or a qualified designee(s). These “trainers” were all trained and examined 

by representatives of Environmental Health and Safety (or a qualified designee), and 

have had a reasonable amount of hands-on experience understanding, applying and 

implementing the OSHA BBP Standard. 


Page 12 of 19 

Revised April 2004

10.3 Elements of Training: Included in the training is/are the epidemiology, symptoms, and 

transmission of bloodborne pathogen diseases. In addition, the training program covers, 

at a minimum, the following elements: 

• copy and explanation of the standard 

• detailed information on HBV, HCV and HIV (signs, symptoms, treatments, etc.) 

• explanation of OU’s ECP and how to obtain a copy 

• explanation of methods to recognize tasks and other activities that may involve 

exposure to blood and OPIM, including what constitutes an exposure incident 

• explanation of the use/limitations of engineering controls, work practices and PPE 

• explanation of the types, uses, location, removal, handling, decontamination, and 

disposal of PPE 

• explanation of the basis for PPE selection 

• information on the hepatitis B vaccine, including information on its efficacy, safety, 

method of administration, benefits of being vaccinated, and that the vaccine will be 

offered free of charge 

• information on the appropriate actions to take and persons to contact in an emergency 

involving blood or OPIM 

• explanation of the procedure to follow if an exposure incident occurs 

• information on the post-exposure evaluation and follow-up that the employer is 

required to provide for the employee following an exposure incident 

• explanation of signs, labels and color coding required by the standard and used at OU 

• an opportunity for interactive questions and answers with the trainer. 

11.0 RECORD KEEPING 

11.1 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 Office of 

Environmental Health and Safety. Training records include for each employee a 

Declaration Form which documents the following: 

• the employee name 

• the date of the training sessions 

• the contents or a summary of the training sessions 

• the name and qualifications of persons conducting the training 

• whether the employee accepted or declined the Hep B vaccination (separate Hep B 

Declination Form provided to all who decline). 

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 

the Office of Environmental Health and Safety. 

11.2 Medical Records: Medical records are maintained for each employee with occupational 

exposure in accordance with 29 CFR 1910.20, "Access to Employee Exposure and 

Medical Records." OU’s Human Resources Department is responsible for maintenance of 

the required medical records for at least the duration of employment plus 30 years. 


Page 13 of 19 

Revised April 2004

11.3 Exposure Incident Evaluation Records: Once an exposure incident (and the associated 

Exposure Incident Report Form) has been evaluated, and any Program modifications put 

into place, these records are maintained in the Office of Environmental Health and 

Safety. 

12.0 CONDITIONS FOR LABS WORKING WITH HIV AND HEPATITIS VIRUSES 

12.1 Working in HIV and Hepatitis Virus "production facilities". 

"Production facility" is defined by OSHA as a facility engaged in industrial-scale, largevolume 

or high concentration production of HIV or Hepatitis Viruses. These activities 

are not currently (as of this July 2000 printing) permitted at OU. 

12.2 Working in HIV and Hepatitis Virus “Research Laboratories” (i.e., laboratories “engaged 

in the culture, production, concentration, experimentation and manipulation of HIV or 

Hepatitis Viruses”. Does NOT apply to clinical or diagnostic laboratories engaged solely 

in the analysis of blood, tissues or organs). 

12.2.1 Minimum Requirements for laboratories engaging in HIV or Hepatitis Virus Research 

• Each laboratory shall contain a facility for hand washing and an eye wash facility 

which is readily available within the work area. 

• An autoclave for decontamination of regulated waste shall be available. 

• All regulated waste shall either be incinerated or decontaminated by a method such as 

autoclaving known to effectively destroy bloodborne pathogens. 

12.2.2 Special Practices 

• Lab doors shall be kept closed when work involving HIV, HBV or HCV is in progress. 

• Contaminated materials that are to be decontaminated at a site away from the work 

area shall be placed in a durable, leakproof, labeled or color-coded container that is 

closed before being removed form the work area. 

• Access to the work area shall be limited to authorized persons. Written policies and 

procedures shall be established whereby only persons who have been advised of the 

potential biohazard, who meet any specific entry requirements, and who comply with 

all entry and exit procedures shall be allowed to enter the work areas. 

• When other potentially infectious materials or infected animals are present in the work 

area or containment module, a hazard warning sign incorporating the universal 

biohazard symbol shall be posted on all access doors. 

• All activities involving other potentially infectious materials shall be conducted in 

biological safety cabinets or other physical-containment devices within the 

containment module; never on the open bench. 


Page 14 of 19 

Revised April 2004

• Laboratory coats, gown, smocks, uniforms, or other appropriate protective clothing 

shall be used in the work area and animals rooms. Protective clothing shall not be 

worn outside of the work area and shall be decontaminated before being laundered. 

• Special care shall be taken to avoid skin or mucous membrane contact with other 

potentially infectious materials - Use gloves and goggles. 

• Before disposal, all waste from work areas and from animals rooms shall be 

decontaminated by a method, e.g., autoclaving, known to effectively destroy BBPs. 

• Vacuum lines shall be protected with liquid disinfectant traps and high efficiency 

particulate air (HEPA) filters or filters of equivalent or superior efficiency and which 

are checked routinely and maintained or replaced as necessary. 

• Hypodermic needles and syringes shall be used only for parenteral injection and 

aspiration of fluids from laboratory animals and diaphragm bottles. Only needlelocking 

syringes or disposable syringe-needle units shall be used for the injection or 

aspiration of other potentially infectious materials. 

• Extreme caution shall be used when handling needles and syringes. A needle shall not 

be bent, sheared, replaced in the sheath or guard, or removed from the syringe 

following use. The needle and syringe shall be promptly placed in a puncture-resistant 

container and autoclaved or decontaminated before reuse or disposal. 

• All spills shall be immediately contained and cleaned up by professional staff properly 

trained/equipped to handle potentially concentrated infectious materials. 

• A spill or accident that results in an exposure incident shall be immediately reported to 

the laboratory director or other responsible person. 

• Employees are required to reference the Oakland University Biosafety Manual for 

instructions on practices and procedures for work with HIV or Hepatitis viruses, and 

follow these procedures. Additionally, an application for use with any infectious 

agents (excluding clinical or diagnostic laboratories engaged solely in the analysis of 

blood, tissues or organs) must be submitted to the Oakland University Biosafety 

Committee; and activities may not commence until the Committee has approved the 

research activities in writing. 


Page 15 of 19 

Revised April 2004

12.2.3 Signs 

The PI or laboratory supervisor shall complete and post the following sign(s) (available 

in the Office of EH&S) at the entrance to all HIV and/or Hepatitis virus research labs: 

12.2.4 Containment Equipment 

• Certified biological safety cabinets (Class I, II, or III) or other appropriate 

combinations of personal protection or physical containment devices, such as special 

protective clothing, respirators, centrifuge safety cups, sealed centrifuge rotors, and 

containment caging for animals, shall be used for all activities with OPIM that pose a 

threat of exposure to droplets, splashes, spills or aerosols. 

• Biological safety cabinets shall be certified upon installation, whenever they are 

moved and at least annually. 

12.2.5 Training Requirements. 

• Additional initial training for employees in HIV, HBV or HBC research laboratories 

shall receive the following initial training in addition to the general training described 

in Section 11.0. 

• Employees must demonstrate proficiency in standard microbiological practices and 

techniques and operations specific to the facility before being allowed to work with 

HIV, HBV or HBC. 

• Employees must have prior experience in the handling of human pathogens or tissue 

cultures before working with HIV, HBV or HCV, or ... 

• Employees (through their supervisors, the OEHS or the OGCSR) must arrange for a 

training program if/when they have no prior experience in handling human pathogens. 

Initial work activities shall not include the handling of infectious agents. A 

progression of work activities shall be assigned as techniques are learned and 

proficiency is developed. Employees may not participate in work activities involving 

infectious agents until proficiency has been demonstrated.

APPENDICES 

BLANK FORMS: 

• Sharps Injury Log (Type I for Non-Laboratories) 

• Sharps Injury Log (Type II for Laboratories) 

• Training and Hep B Declaration Form 

• Hep B Declination Form 

• Hepatitis B Vaccination - Status Form 

• Exposure Incident Report Form 

• Post-Exposure Incident Checklist 

• Sharps Injury Log (Type I) 

• Sharps Injury Log (Type II) 

• Blood Draw Consensus Form - Source Individual 

• PPE Exception Form 

• Research Activities Involving Direct Manipulation of Bloodborne Pathogens - Report 

Form 

COMPLETED FORMS (WHERE APPLICABLE - DEPT. SPECIFIC): 

• Pre-exposure Hepatitis B Vaccination - Status Form 

• Completed Hepatitis B Declaration/Declination Forms 

• Exposure Incident Report Form 

• Post-Exposure Incident Checklist 

• Blood Draw Consensus Form - Source Individual 

• PPE Exception Form 

• Research Activities Involving Direct Manipulation of Bloodborne Pathogens - Report 

Form 

UNIVERSAL PRECAUTIONS 

OSHA BLOODBORNE PATHOGENS STANDARD 




Sharps Injury Log 

Page _____ 

Date of 

Incident 

Name of Injured 

Job Title of 

Injured 

Type of Needle 

Involved 

Describe how 

Needle stick 

Occurred 

Steps taken 

Immediately 

After Stick 

Steps taken to 

Avoid Future 

Needle sticks

Training Date 

BBP TRAINING AND HBV VACCINATION DECLARATION FORM 


Department ____________________________________ 

Name Job Classification __________________________ 

TRAINING: I hereby certify that I have received training in bloodborne pathogens exposure control. This 

training included providing me a copy of the BBP Exposure Control Standard, and an explanation of the 

following: OU’s Exposure Control Plan and how to obtain a copy; details regarding transmission, signs, symptoms 

and prognoses of common BBP viruses (i.e., HBV, HCV and HIV); common methods to recognize tasks and other 

activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident, the use 

and limitations of engineering controls, work practices and personal protective equipment (PPE); the types, uses, 

location, removal, handling, decontamination and disposal of PPE; the basis for PPE selection; the hepatitis b 

vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, 

and that the vaccine is offered free of charge under certain circumstances; the appropriate actions to take and 

persons to contact in an emergency involving blood or OPIM; 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 OU is required to provide me following an 

exposure incident; the signs and labels and/or color-coding required by the BBP Standard and OU. I further 

certify that I was provided ample opportunity for interactive questions and answers with the person(s) 

conducting the training session. 

The training was provided to me by “qualified” personnel as follows: General information regarding BBP 

viruses and exposure control was provided to me by OU’s Office of Environmental Health and Safety, either in 

person or via a handout generated by the Officeof EH&S and provided me by my supervisor. This EH&S training 

staff has had extensive formal training in, and experience with, interpreting and implementing the BBP Standard, 

and designing and providing training in this area. Site-specific information, regarding BBP exposure control in my 

department as it relates to the occupational activities I perform, was subsequently provided me by my supervisor 

(who received his/her guidance, training and handouts directly from the Office of EH&S). 

HEPATITIS B VACCINATION: While the HBV vaccine is well tolerated by most people, and provides 

significant protection against acquiring HBV-related illnesses, vaccination has some inherent risks (including, but 

not limited to, swelling, reddening, post injection soreness, body fatigue, headache, muscle or joint soreness), as 

well as some medical contra-indications (including, but not limited to, high blood pressure, allergies to yeast/mold, 

pregnancy), so I understand that my health care professional (in conference with myself) shall decide and document 

whether it is safe for me to obtain the HBV vaccination. 

I have read each option below and understand each of them. I have selected ONE option by placing a Τ. I also 

understand that I may change my mind at any time. Finally, if I select Option 2. below, I understand that I 

must also complete a SEPARATE Hepatitis b Declination form. 

1. ______ I would like to have OU pay for my HBV vaccination series; I understand that MIOSHA requires me 

to begin the immunization process within 10 calendar days of accepting this vaccination. 

2. ______I decline to have OU pay for my HBV vaccinations because (place a Τ in appropriate blank below). 

________ a) I have already been immunized; 

OR 

________ b) I would like OU to pay for the antibody test (i.e., “titer”) performed before deciding; 

OR 

________ c) cost of said immunization is 100% funded by another source (e.g., medical insurance); OR 

I understand that if I select this Option, I must also complete a separate Hepatitis B Declination Form 

_ 

3. _____ Based on my OU job classification (identified above), my “PRIMARY” occupational duties do not 

present “reasonably anticipated exposure to blood or OPIM”, and I am therefore not eligible to receive “preexposure” 

hepatitis b vaccination funding. I understand, however, that should I be involved in any 

occupational incident that involves human blood or OPIM (regardless of whether “exposure” occurs), I am 

then eligible to receive (at no cost) an accelerated series of hepatitis b vaccinations, which should begin 

within 24 hours, but up to 7 calendar days, after the incident. Note: Those who are required, encouraged 

and/or allowed to provide first-aid on campus as a “collateral” job responsibility (for example, athletic 

coaches) would select this Option. 

SIGNED: 

DATE: ______________ 

[Requires signature of Legal Guardian if under age 18 - print words “legal guardian” next to signature if applicable]

BBP TRAINING AND HBV VACCINATION DECLARATION FORM 

Oakland University - School of Nursing 

Training Date Name __________________________________ 

TRAINING: I hereby certify that I have received training in bloodborne pathogens exposure control. This training included 

providing me a copy of the BBP Exposure Control Standard, and an explanation of the following: OU’s Exposure Control 

Plan and how to obtain a copy; details regarding transmission, signs, symptoms and prognoses of common BBP viruses (i.e., 

HBV, HCV and HIV); common methods to recognize tasks and other activities that may involve exposure to blood and OPIM, 

including what constitutes an exposure incident, the use and limitations of engineering controls, work practices and personal 

protective equipment (PPE); the types, uses, location, removal, handling, decontamination and disposal of PPE; the basis for 

PPE selection; the hepatitis b vaccine, including information on its efficacy, safety, method of administration, the benefits of 

being vaccinated, and that the vaccine is offered free of charge under certain circumstances; the appropriate actions to take and 

persons to contact in an emergency involving blood or OPIM; 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 OU is required to provide me following an exposure incident; the signs and labels and/or colorcoding 

required by the BBP Standard and OU. I further certify that I was provided ample opportunity for interactive questions 

and answers with the person(s) conducting the training session. 

The training was provided to me by “qualified” personnel as follows: General information regarding the BBP Exposure 

Control Standard, transmission and signs/symptoms of common BBP Viruses (e.g., HBV, HCV and HIV) was provided to me by 

either in person, and/or via live instruction, video-tape, or handout, by a Nursing Department faculty member (in conjunction 

with OU’s Office of Environmental Health and Safety). The Office of EH&S training staff has had extensive formal training in, 

and experience with, interpreting and implementing the BBP Standard; likewise Nursing Department faculty members, based on 

the nature of their nursing educations, are naturally well versed in BBP Exposure Controls. I further understand that the 

responsibility for site-specific training (as it relates to the actual duties I perform at my site(s) of employment) is/was the 

responsibility of similarly qualified nursing administrators/supervisors at the facilities at which I perform these duties. 

HEPATITIS B VACCINATION: While the HBV vaccine is well tolerated by most people, and provides significant protection 

against acquiring HBV-related illnesses, vaccination has some inherent risks (including, but not limited to, swelling, reddening, 

post injection soreness, body fatigue, headache, muscle or joint soreness), as well as some medical contra-indications (including, 

but not limited to, high blood pressure, allergies to yeast/mold, pregnancy), so I understand that my health care professional (in 

conference with myself) shall decide and document whether it is safe for me to obtain the HBV vaccination. 

I have read each option below and understand each of them. I have selected ONE option by placing a Τ. I also understand that 

I may change my mind at any time. Finally, if I select Option 2. below, I understand that I must also complete a 

SEPARATE “Hepatitis b Declination Form”. 

1. ____I would like to have OU pay for my HBV vaccination series; I understand that MIOSHA requires me to begin the 

immunization process within 10 calendar days of accepting this vaccination series. 

2. _____I decline to have OU pay for my HBV vaccinations because (place a Τ in appropriate blank below). 

_____ a) I have already been immunized; OR 

_____ b) I would like OU to pay for the antibody test (i.e., “titer”) performed before deciding; OR 

_____ c) cost of said immunization is 100% funded by another source (e.g., medical insurance); OR 

_____ d) personal reasons 

I understand that if I select Option 2., I must also complete a separate Hepatitis B Declination Form: 

3. ______Based on my OU job classification (identified below), my occupational duties do not present “reasonably anticipated 

exposure to blood or OPIM”, and I am therefore not eligible to receive “pre-exposure” hepatitis b vaccination funding. I 

understand, however, that should I be involved in any occupational incident that involves human blood or OPIM (regardless 

of whether “exposure” occurs), I am then eligible to receive an accelerated series of hepatitis b vaccinations, which should 

begin within 24 hours (but up to 7 days) after the incident. 

SIGNED: 

Job Classification [PLEASE CHECK ONE]: 

_____ Learning Resources Lab Instructor 

_____ Clinical Instructor 

_____ Other (specify here) ________________________________ 

DATE: ______________________________

HBV VACCINATION DECLINATION FORM 

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 my 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 (OPIM) and I 

want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no 

charge to me. 

Name (printed) ______________________________________ 

Department _________________________________________ 

Job Classification ____________________________________ 

Signature ____________________________________________________________________________ 

[Requires signature of Legal Guardian if under age 18 - print words “legal guardian” next to signature if applicable] 

Social Security Number (REQUIRED BY MIOSHA) __________________________ 

[Wording direct from 29 CFR’s Appendix to Section 1910.1030-Hepatitis B Vaccine Declination (Mandatory)]

"PRE-EXPOSURE" HEPATITIS B VACCINATION 

STATUS FORM 

Department ______________________________________________________ 

ELIGIBLE 

EMPLOYEE 

NAME 

ACCEPTED/ 

DECLINED 

VACCINATION 

and DATE DECIDED 

DATES 

VACCINE 

RECEIVED 

#1/#2/#3 

ADMINISTERING 

HEALTH 

CARE FACILITY

EXPOSURE INCIDENT REPORT FORM 

Date of Incident 

Job site/location: 

Time of Incident _________________________ 

Name of Employee____________________________ 

Job Description (Description of General Duties): ________________________________________ 

Potentially Infectious Material Involved (e.g. blood etc.) _________________________________ 

Source of Potentially Infectious Material (e.g. needle-stick, cut, bite etc.) ____________________ 

Circumstances Surrounding Exposure Incident (e.g. work being performed etc.) _______________ 

_______________________________________________________________________________ 

Route of Exposure (e.g. under-the-skin, unprotected skin, eyes, nose, mouth) _________________ 

_______________________________________________________________________________ 

How Exposure Occurred (e.g. equipment malfunction, human error, etc.) ____________________ 

_______________________________________________________________________________ 

Personal Protection Equipment Worn at Time of Incident ________________________________ 

_______________________________________________________________________________ 

_______________________________________________________________________________ 

Actions Taken at Time of Incident (e.g. soap/water clean-up, reporting to supervisor etc.) 

_______________________________________________________________________________ 

_______________________________________________________________________________ 

_______________________________________________________________________________ 

Recommendations for Avoiding Repetition: ___________________________________________ 

_______________________________________________________________________________ 

_______________________________________________________________________________

POST-EXPOSURE INCIDENT CHECKLIST 

The following steps must be taken, and information provided, in the event of an employee's exposure to 

blood or other potentially infectious material. 

Date of Exposure Incident _______________________________ 

ACTIVITY 

• Contaminated area was washed with soap and water (or eyewash if the eye) for 

at least 15 minutes. 

• Employee transported to emergency room within 2 hours of incident for antiviral 

drugs (following washing/flushing described above). 

• Employee furnished with documentation regarding exposure incident. 

• The following documentation was forwarded to a Healthcare Professional who 

is evaluating employee: 

o Bloodborne Pathogens Standard 

o Exposure Incident Report 

o Employee’s medical records 

COMPLETION 

____________ 

____________ 

____________ 

____________ 

____________ 

____________ 

• Source Individual: 

o Identified OR it was determined that ID was not feasible (circle one) 

o Authorization to collect blood requested 

o Blood tested OR authorization refused (circle one) 

____________ 

____________ 

____________ 

• Source individual’s blood results given to exposed employee ____________ 

• Employee informed than any/all follow-up care shall be at no cost to him/her ____________

Authorization to Have Blood Drawn and 

Analyzed for Presence of Viral Infection 

Source Individual Consent Form 

1. Individual's Name 

Social Security Number 

Date of Birth 

2. I authorize_______________________(Name of Health Care Facility) to draw and analyze my blood 

for the presence of viral (i.e., HBV or HIV) infection. 

3. I understand that the results of this analysis shall be made available to the individual who has been 

exposed to my blood (in addition to his/her health care provider), and maintained in that individual's 

CONFIDENTIAL medical records on file at OU. 

4. I agree that a photocopy or facsimile of this authorization shall be as valid as the original. 

__________________________________________________ 

Signed (source individual) 

_________________________ 

Date 

____________________________________________________ 

Parent or guardian (if individual is under 18 years of age) 

_________________________ 

Date

PPE EXCEPTION FORM 

Name of Individual Completing Form 

On (date) __________________________ I voluntarily and knowingly chose against wearing 

Personal Protective Equipment (PPE) even though I was aware that the task I was performing 

introduced a risk of exposure to Bloodborne Pathogens. 

In my judgement, in this specific instance, obtaining/using PPE would have (check one): 

_____ prevented the delivery of health care or public safety services; 

_____ posed an increased hazard to the safety of a victim, myself or coworker(s); or 

______ other, explain in next paragraph. 

Description of task I was performing, and detailed reason for choosing against PPE: 

______________________________________________________________________________________ 

__________________________________________________________________________________ 

Suggestions for avoiding this situation in the future: 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

Signed 

Co-Signed Employee Supervisor 

Date 

Date

RESEARCH ACTIVITIES INVOLVING DIRECT MANIPULATION OF 

BLOODBORNE PATHOGENS 

REPORT FORM 

Department: 

“MANIPULATION” 

PROCEDURE(S) 

(e.g. assay, culture, 

centrifuge, etc.) 

BLOODBORNE 

PATHOGENS 

BEING MANIPULATED 

LOCATION(S) 

PERFORMED 

REC’D OU 

BIOSAFETY 

COMMITTEE 

APPROVAL 

(Date and PI 

signature) 

* “Manipulation” includes, but is not limited to, culturing, assaying, centrifuging, handling, pipetting 

etc. of infectious organisms carried in human blood.

"UNIVERSAL” 

BLOOD AND BODY FLUID 

PRECAUTIONS 

+ 

OSHA BLOODBORNE PATHOGEN 

STANDARD 

[29 CFR 1910.1030]

Page 31 of 19

OSHA Regulations (Standards - 29 CFR) 

Bloodborne Pathogens. - 1910.1030 

Standard Number: 1910.1030 

Standard Title: Bloodborne 

pathogens. 

SubPart Number: Z 

SubPart Title: Toxic and Hazardous 

Substances 

(a) Scope and Application. This 

section applies to all occupational 

exposure to blood or other potentially 

infectious materials as defined by 

paragraph (b) of this section. 

(b) Definitions. For purposes of this 

section, the following shall apply: 

"Assistant Secretary" means the 

Assistant Secretary of Labor for 

Occupational Safety and Health, or 

designated representative. 

"Blood" means human blood, human 

blood components, and products made 

from human blood. 

"Bloodborne Pathogens" means 

pathogenic microorganisms that are 

present in human blood and can cause 

disease in humans. These pathogens 

include, but are not limited to, 

hepatitis B virus (HBV) and human 

immunodeficiency virus (HIV). 

"Clinical Laboratory" means a 

workplace where diagnostic or other 

screening procedures are performed 

on blood or other potentially 

infectious materials. 

"Contaminated" means the presence 

or the reasonably anticipated presence 

of blood or other potentially infectious 

materials on an item or surface. 

"Contaminated Laundry" means 

laundry which has been soiled with 

blood or other potentially infectious 

materials or may contain sharps. 

"Contaminated Sharps" means any 

contaminated object that can penetrate 

the skin including, but not limited to, 

needles, scalpels, broken glass, broken 

capillary tubes, and exposed ends of 

dental wires. 

"Decontamination" means the use of 

physical or chemical means to 

remove, inactivate, or destroy 

"Source Individual" means any 

individual, living or dead, whose 


materials may be a source of 

occupational exposure to the 

bloodborne pathogens on a surface 

or item to the point where they are 

no longer capable of transmitting 

infectious particles and the surface 

or item is rendered safe for 

handling, use, or disposal. 

"Director" means the Director of 

the National Institute for 

Occupational Safety and Health, 

U.S. Department of Health and 

Human Services, or designated 

representative. 

"Engineering Controls" means 

controls (e.g., sharps disposal 

containers, self-sheathing needles) 

that isolate or remove the 

bloodborne pathogens hazard from 

the workplace. 

"Exposure Incident" means a 

specific eye, mouth, other mucous 

membrane, non-intact skin, or 

parenteral contact with blood or 

other potentially infectious 

materials that results from the 

performance of an employee's 

duties. 

"Handwashing Facilities" means a 

facility providing an adequate 

supply of running potable water, 

soap and single use towels or hot 

air drying machines. 

"Licensed Healthcare 

Professional" is a person whose 

legally permitted scope of practice 

allows him or her to independently 

perform the activities required by 

paragraph (f) Hepatitis B 

Vaccination and Post-exposure 

Evaluation and Follow-up. 

"HBV" means hepatitis B virus. 

"HIV" means human 

immunodeficiency virus. 

"Occupational Exposure" means 

reasonably anticipated skin, eye, 

mucous membrane, or parenteral 

contact with blood or other 

potentially infectious materials that 

may result from the performance of 

an employee's duties. 

employee. Examples include, but 

are not limited to, hospital and 

clinic patients; clients in 

institutions for the developmentally 

disabled; trauma victims; clients of 

"Other Potentially Infectious Materials" 

(OPIM) means (1) The following human 

body fluids: semen, vaginal secretions, 

cerebrospinal fluid, synovial fluid, pleural 

fluid, pericardial fluid, peritoneal fluid, 

amniotic fluid, saliva in dental procedures, 

any body fluid that is visibly contaminated 

with blood, and all body fluids in 

situations where it is difficult or 

impossible to differentiate between body 

fluids; (2) Any unfixed tissue or organ 

(other than intact skin) from a human 

(living or dead); and (3) HIV-containing 

cell or tissue cultures, organ cultures, and 

HIV- or HBV-containing culture medium 

or other solutions; and blood, organs, or 

other tissues from experimental animals 

infected with HIV or HBV. 

"Parenteral" means piercing mucous 

membranes or the skin barrier through 

such events as needlesticks, human bites, 

cuts, and abrasions. 

"Personal Protective Equipment" is 

specialized clothing or equipment worn by 

an employee for protection against a 

hazard. General work clothes (e.g., 

uniforms, pants, shirts or blouses) not 

intended to function as protection against a 

hazard are not considered to be personal 

protective equipment. 

"Production Facility" means a facility 

engaged in industrial-scale, large-volume 

or high concen. produc. of HIV or HBV. 

"Regulated Waste" means liquid or semiliquid 


materials; contaminated items that would 

release blood or other potentially 

infectious materials in a liquid or semiliquid 

state if compressed; items that are 

caked with dried blood or other potentially 

infectious materials and are capable of 

releasing these materials during handling; 

contaminated sharps; and pathological and 

microbiological wastes containing blood or 

other potentially infectious materials. 

"Research Laboratory" means a laboratory 

producing or using research-laboratoryscale 

amounts of HIV or HBV. Research 

laboratories may produce high 

concentrations of HIV or HBV but not in 

the volume found in production facilities. 

drug and alcohol treatment facilities; 

residents of hospices and nursing homes; 

human remains; and individuals who 

donate or sell blood or blood components.

"Sterilize" means the use of a physical 

or chemical procedure to destroy all 

microbial life including highly 

resistant bacterial endospores. 

"Universal Precautions" is an 

approach to infection control. 

According to the concept of Universal 

Precautions, all human blood and 

certain human body fluids are treated 

as if known to be infectious for HIV, 

HBV, and other bloodborne 

pathogens. 

"Work Practice Controls" means 

controls that reduce the likelihood of 

exposure by altering the manner in 

which a task is performed (e.g., 

prohibiting recapping of needles by a 

two-handed technique). 

(c) Exposure Control. 

(c)(1) Exposure Control Plan. 

(c)(1)(i) Each employer having an 

employee(s) with occupational 

exposure as defined by paragraph (b) 

of this section shall establish a written 

Exposure Control Plan designed to 

eliminate or minimize employee 

exposure. 

(c)(1)(ii) The Exposure Control Plan 

shall contain at least the following 

elements: 

(c)(1)(ii)(A) The exposure 

determination required by paragraph 

(c)(2), 

(c)(1)(ii)(B) The schedule and method 

of implementation for paragraphs (d) 

Methods of Compliance, (e) HIV and 

HBV Research Laboratories and 

Production Facilities, (f) Hepatitis B 

Vaccination and Post-Exposure 

Evaluation and Follow-up, (g) 

Communication of Hazards to 

Employees, and (h) Recordkeeping, of 

this standard, and 

(c)(1)(ii)(C) The procedure for the 

evaluation of circumstances 

surrounding exposure incidents as 

required by paragraph (f)(3)(i) of this 

standard. 

(c)(1)(iii) Each employer shall ensure 

that a copy of the Exposure Control 

Plan is accessible to employees in 

(d)(2)(vii)(B) Such bending, 

recapping or needle removal must be 

accomplished through the use of a 

mechanical device or a one-handed 

technique. 

(d)(2)(viii) Immediately or as soon as 

possible after use, contaminated 

accordance with 29 CFR 

1910.1020(e). 

(c)(1)(iv) The Exposure Control 

Plan shall be reviewed and updated 

at least annually and whenever 

necessary to reflect new or 

modified tasks and procedures 

which affect occupational exposure 

and to reflect new or revised 

employee positions with 

occupational exposure. 

(c)(1)(v) The Exposure Control 

Plan shall be made available to the 

Assistant Secretary and the 

Director upon request for 

examination and copying. 

(c)(2) Exposure Determination. 

(c)(2)(i) Each employer who has an 

employee(s) with occupational 

exposure as defined by paragraph 

(b) of this section shall prepare an 

exposure determination. This exp. 

determ. shall contain the following: 

(c)(2)(i)(A) A list of all job 

classifications in which all 

employees in those job 

classifications have occupational 

exposure; 

(c)(2)(i)(B) A list of job 

classifications in which some 

employees have occupational 

exposure, and 

(c)(2)(i)(C) A list of all tasks and 

procedures or groups of closely 

related tasks and procedures in 

which occupational exposure 

occurs and that are performed by 

employees in job classifications 

listed in accordance with the 

provisions of paragraph (c)(2)(i)(B) 

of this standard. 

(c)(2)(ii) This exposure 

determination shall be made 

without regard to the use of 

personal protective equipment. 

(d) Methods of Compliance. 

(d)(1) General. Universal 

precautions shall be observed to 

prevent contact with blood or other 

potentially infectious materials. 

Under circumstances in which 

differentiation between body fluid 

reusable sharps shall be placed in 

appropriate containers until 

properly reprocessed. These 

containers shall be: 

(d)(2)(viii)(A) puncture resistant; 

types is difficult or impossible, all body 

fluids shall be considered potentially 


(d)(2) Engineering and Work Practice 

Controls. 

(d)(2)(i) 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. 

(d)(2)(ii) Engineering controls shall be 

examined and maintained or replaced on a 

regular schedule to ensure effectiveness. 

(d)(2)(iii) Employers shall provide 

handwashing facilities which are readily 

accessible to employees. 

(d)(2)(iv) When provision of handwashing 

facilities is not feasible, the employer shall 

provide either an appropriate antiseptic 

hand cleanser in conjunction with clean 

cloth/paper towels or antiseptic towelettes. 

When antiseptic hand cleansers or 

towelettes are used, hands shall be washed 

with soap and running water as soon as 

feasible. 

(d)(2)(v) Employers shall ensure that 

employees wash their hands immediately 

or as soon as feasible after removal of 

gloves or other personal protective 

equipment. 

(d)(2)(vi) Employers 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 blood or other potentially 


(d)(2)(vii) Contaminated needles and other 

contaminated sharps shall not be bent, 

recapped, or removed except as noted in 

paragraphs (d)(2)(vii)(A) and 

(d)(2)(vii)(B) below. Shearing or breaking 

of contaminated needles is prohibited. 

(d)(2)(vii)(A) Contaminated needles and 

other contaminated sharps shall not be 

bent, recapped or removed unless the 

employer can demonstrate that no 

alternative is feasible or that such action is 

required by a specific medical or dental 

procedure. 

(d)(2)(viii)(B) labeled or color-coded in 

accordance with this standard; 

(d)(2)(viii)(C) leakproof on the sides and 

bottom; and

(d)(2)(viii)(D) in accordance with the 

requirements set forth in paragraph 

(d)(4)(ii)(E) for reusable sharps. 

(d)(2)(ix) 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. 

(d)(2)(x) 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. 

(d)(2)(xi) All procedures involving 


materials shall be performed in such a 

manner as to minimize splashing, 

spraying, spattering, and generation of 

droplets of these substances. 

(d)(2)(xii) Mouth pipetting/suctioning 

of blood or other potentially infectious 

materials is prohibited. 

(d)(2)(xiii) Specimens of blood or 

other potentially infectious materials 

shall be placed in a container which 

prevents leakage during collection, 

handling, processing, storage, 

transport, or shipping. 

(d)(2)(xiii)(A) The container for 

storage, transport, or shipping shall be 

labeled or color-coded according to 

paragraph (g)(1)(i) and closed prior to 

being stored, transported, or shipped. 

When a facility utilizes Universal 

Precautions in the handling of all 

specimens, the labeling/color-coding 

of specimens is not necessary 

provided containers are recognizable 

as containing specimens. This 

exemption only applies while such 

specimens/containers remain within 

the facility. Labeling or color-coding 

in accordance with paragraph (g)(1)(i) 

is required when such 

specimens/containers leave the 

facility. 

(d)(3)(vi) If a garment(s) is penetrated 

by blood or other potentially 

infectious materials, the garment(s) 

shall be removed immediately or as 

soon as feasible. 

(d)(3)(vii) All personal protective 

equipment shall be removed prior to 

leaving the work area. 

(d)(2)(xiii)(B) If outside 

contamination of the primary 

container occurs, the primary 

container shall be placed within a 

second container which prevents 

leakage during handling, 

processing, storage, transport, or 

shipping and is labeled or colorcoded 

according to the 

requirements of this standard. 

(d)(2)(xiii)(C) If the specimen 

could puncture the primary 

container, the primary container 

shall be placed within a secondary 

container which is punctureresistant 

in addition to the above 

characteristics. 

(d)(2)(xiv) Equipment which may 

become contaminated with blood or 

other potentially infectious 

materials shall be examined prior to 

servicing or shipping and shall be 

decontaminated as necessary, 

unless the employer can 

demonstrate that decontamination 

of such equipment or portions of 

such equipment is not feasible. 

(d)(2)(xiv)(A) A readily observable 

label in accordance with paragraph 

(g)(1)(i)(H) shall be attached to the 

equipment stating which portions 

remain contaminated. 

(d)(2)(xiv)(B) The employer shall 

ensure that this information is 

conveyed to all affected employees, 

the servicing representative, and/or 

the manufacturer, as appropriate, 

prior to handling, servicing, or 

shipping so that appropriate 

precautions will be taken. 

(d)(3) Personal Protective 

Equipment. 

(d)(3)(i) Provision. When there is 

occupational exposure, the 

employer shall provide, at no cost 

to the employee, appropriate 

personal protective equipment such 

as, but not limited to, gloves, 

gowns, laboratory coats, face 

shields or masks and eye 

(d)(3)(viii) When personal 

protective equipment is removed it 

shall be placed in an appropriately 

designated area or container for 

storage, washing, decontamination 

or disposal. 

(d)(3)(ix) Gloves. Gloves shall be 

worn when it can be reasonably 

anticipated that the employee may 

protection, and mouthpieces, resuscitation 

bags, pocket masks, or other ventilation 

devices. Personal protective equipment 

will be considered "appropriate" only if it 

does not permit blood or other potentially 

infectious materials to pass through to or 

reach the employee's work clothes, street 

clothes, undergarments, skin, eyes, mouth, 

or other mucous membranes under normal 

conditions of use and for the duration of 

time which the protective equipment will 

be used. 

(d)(3)(ii) Use. The employer shall ensure 

that the employee uses appropriate 

personal protective equipment unless the 

employer shows that the employee 

temporarily and briefly declined to use 

personal protective equipment when, under 

rare and extraordinary circumstances, it 

was the employee's professional judgment 

that in the specific instance its use would 

have prevented the delivery of health care 

or public safety services or would have 

posed an increased hazard to the safety of 

the worker or co-worker. When the 

employee makes this judgement, the 

circumstances shall be investigated and 

documented in order to determine whether 

changes can be instituted to prevent such 

occurrences in the future. 

(d)(3)(iii) Accessibility. The employer 

shall ensure that appropriate personal 

protective equipment in the appropriate 

sizes is readily accessible at the worksite 

or is issued to employees. Hypoallergenic 

gloves, glove liners, powderless gloves, or 

other similar alternatives shall be readily 

accessible to those employees who are 

allergic to the gloves normally provided. 

(d)(3)(iv) Cleaning, Laundering, and 

Disposal. The employer shall clean, 

launder, and dispose of personal protective 

equipment required by paragraphs (d) and 

(e) of this standard, at no cost to the 

employee 

(d)(3)(v) Repair and Replacement. The 

employer shall repair or replace personal 

protective equipment as needed to 

maintain its effectiveness, at no cost to the 

employee. 

have hand contact with blood, other 

potentially infectious materials, mucous 

membranes, and non-intact skin; when 

performing vascular access procedures 

except as specified in paragraph 

(d)(3)(ix)(D); and when handling or 

touching contaminated items or surfaces. 

(d)(3)(ix)(A) Disposable (single use) 

gloves such as surgical or examination

gloves, shall be replaced as soon as 

practical when contaminated or as 

soon as feasible if they are torn, 

punctured, or when their ability to 

function as a barrier is compromised. 

(d)(3)(ix)(B) Disposable (single use) 

gloves shall not be washed or 

decontaminated for re-use. 

(d)(3)(ix)(C) Utility gloves may be 

decontaminated for re-use 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 or when their ability 

to function as a barrier is 

compromised. 

(d)(3)(ix)(D) If an employer in a 

volunteer blood donation center 

judges that routine gloving for all 

phlebotomies is not necessary then the 

employer shall: 

(d)(3)(ix)(D)(1) Periodically 

reevaluate this policy; 

(d)(3)(ix)(D)(2) Make gloves 

available to all employees who wish 

to use them for phlebotomy; 

(d)(3)(ix)(D)(3) Not discourage the 

use of gloves for phlebotomy; and 

(d)(3)(ix)(D)(4) Require that gloves 

be used for phlebotomy in the 

following circumstances: 

[i] When the employee has cuts, 

scratches, or other breaks in his or her 

skin; 

[ii] When the employee judges that 

hand contamination with blood may 

occur, for example, when performing 

phlebotomy on an uncooperative 

source individual; and 

[iii] When the employee is receiving 

training in phlebotomy. 

(d)(3)(x) Masks, Eye Protection, and 

Face Shields. Masks in combination 

with eye protection devices, such as 

[b] Puncture resistant; 

[c] Leakproof on sides and bottom; 

and 

[d] Labeled or color-coded in 

accordance with paragraph (g)(1)(i) of 

this standard. 

(d)(4)(iii)(A)(2) During use, 

containers for contaminated sharps 

shall be: 

[a] Easily accessible to personnel and 

located as close as is feasible to the 

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 

materials may be generated and 

eye, nose, or mouth contamination 

can be reasonably anticipated. 

(d)(3)(xi) Gowns, Aprons, and 

Other Protective Body Clothing. 

Appropriate protective clothing 

such as, but not limited to, gowns, 

aprons, lab coats, clinic jackets, or 

similar outer garments shall be 

worn in occupational exposure 

situations. The type and 

characteristics will depend upon the 

task and degree of exposure 

anticipated. 

(d)(3)(xii) Surgical caps or hoods 

and/or shoe covers or boots shall be 

worn in instances when gross 

contamination can reasonably be 

anticipated (e.g., autopsies, 

orthopaedic surgery). 

(d)(4) Housekeeping. 

(d)(4)(i) General. Employers shall 

ensure that the worksite is 

maintained in a clean and sanitary 

condition. The employer shall 

determine and implement an 

appropriate written schedule for 

cleaning and method of 

decontamination based upon the 

location within the facility, type of 

surface to be cleaned, type of soil 

present, and tasks or procedures 

being performed in the area. 

(d)(4)(ii) All equipment and 

environmental and working 

surfaces shall be cleaned and 

decontaminated after contact with 


materials. 

(d)(4)(ii)(A) Contaminated work 

surfaces shall be decontaminated 

with an appropriate disinfectant 

immediate area where sharps are 

used or can be reasonably 

anticipated to be found (e.g., 

laundries); 

[b] Maintained upright throughout 

use; and 

[c] Replaced routinely and not be 

allowed to overfill. 

(d)(4)(iii)(A)(3) When moving 

containers of contaminated sharps 

from the area of use, the containers 

shall be: 

after completion of procedures; 

immediately or as soon as feasible when 

surfaces are overtly contaminated 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. 

(d)(4)(ii)(B) Protective coverings, such as 

plastic wrap, aluminum foil, or 

imperviously-backed absorbent paper used 

to cover equipment and environmental 

surfaces, shall be removed and replaced as 

soon as feasible when they become overtly 

contaminated or at the end of the workshift 

if they may have become contaminated 

during the shift. 

(d)(4)(ii)(C) All bins, pails, cans, and 

similar receptacles intended for reuse 

which have a reasonable likelihood for 

becoming contaminated with blood or 

other potentially infectious materials shall 

be inspected and decontaminated on a 

regularly scheduled basis and cleaned and 

decontaminated immediately or as soon as 

feasible upon visible contamination. 

(d)(4)(ii)(D) Broken glassware which may 

be contaminated shall not be picked up 

directly with the hands. It shall be cleaned 

up using mechanical means, such as a 

brush and dust pan, tongs, or forceps. 

(d)(4)(ii)(E) Reusable sharps that are 

contaminated with blood or other 

potentially infectious materials shall not be 

stored or processed in a manner that 

requires employees to reach by hand into 

the containers where these sharps have 

been placed. 

(d)(4)(iii) Regulated Waste. 

(d)(4)(iii)(A) Contaminated Sharps 

Discarding and Containment. 

(d)(4)(iii)(A)(1) Contaminated sharps shall 

be discarded immediately or as soon as 

feasible in containers that are: 

[a] Closable; 

[a] Closed immediately prior to removal or 

replacement to prevent spillage or 

protrusion of contents during handling, 

storage, transport, or shipping; 

[b] Placed in a secondary container if 

leakage is possible. The second container 

shall be: 

[i] Closable; 

[ii] Constructed to contain all contents and 

prevent leakage during handling, storage, 

transport, or shipping; and

[iii] Labeled or color-coded according 

to paragraph (g)(1)(i) of this standard. 

(d)(4)(iii)(A)(4) Reusable containers 

shall not be opened, emptied, or 

cleaned manually or in any other 

manner which would expose 

employees to the risk of percutaneous 

injury. 

(d)(4)(iii)(B) Other Regulated Waste 

Containment. 

(d)(4)(iii)(B)(1) Regulated waste shall 

be 

placed in containers which are: 

[a] Closable; 

[b] Constructed to contain all contents 

and prevent leakage of fluids during 

handling, storage, transport or 

shipping; 

[c] Labeled or color-coded in 

accordance with paragraph (g)(1)(i) 

this standard; and 

[d] Closed prior to removal to prevent 

spillage or protrusion of contents 

during handling, storage, transport, or 

shipping. 

(d)(4)(iii)(B)(2) If outside 

contamination of the regulated waste 

container occurs, it shall be placed in 

a second container. The second 

container shall be: 

[a] Closable; 

[b] Constructed to contain all contents 

and prevent leakage of fluids during 

handling, storage, transport or 

shipping; 

[c] Labeled or color-coded in 

accordance with paragraph (g)(1)(i) of 

this standard; and 

[d] Closed prior to removal to prevent 

spillage or protrusion of contents 

during handling, storage, transport, or 

shipping. 

(d)(4)(iii)(C) Disposal of all regulated 

waste shall be in accordance with 

applicable regulations of the United 

States, States and Territories, and 

political subdivisions of States and 

Territories. 

(d)(4)(iv) Laundry. 

(d)(4)(iv)(A) Contaminated laundry 

shall be handled as little as possible 

with a minimum of agitation. 

(d)(4)(iv)(A)(1) Contaminated 

laundry shall be bagged or 

containerized at the location where it 

was used and shall not be sorted or 

rinsed in the location of use. 

(d)(4)(iv)(A)(2) Contaminated 

laundry shall be placed and 

transported in bags or containers 

labeled or color-coded in 

accordance with paragraph (g)(1)(i) 

of this standard. When a facility 

utilizes Universal Precautions in 

the handling of all soiled laundry, 

alternative labeling or color-coding 

is sufficient if it permits all 

employees to recognize the 

containers as requiring compliance 

with Universal Precautions. 

(d)(4)(iv)(A)(3) Whenever 

contaminated laundry is wet and 

presents a reasonable likelihood of 

soak-through of or leakage from the 

bag or container, the laundry shall 

be placed and transported in bags 

or containers which prevent soakthrough 

and/or leakage of fluids to 

the exterior. 

(d)(4)(iv)(B) The employer shall 

ensure that employees who have 

contact with contaminated laundry 

wear protective gloves and other 

appropriate personal protective 

equipment. 

(d)(4)(iv)(C) When a facility ships 

contaminated laundry off-site to a 

second facility which does not 

utilize Universal Precautions in the 

handling of all laundry, the facility 

generating the contaminated 

laundry must place such laundry in 

bags or containers which are 

labeled or color-coded in 

accordance with paragraph 

(g)(1)(i). 

(e) HIV and HBV Research 

Laboratories and Production 

Facilities. 

(e)(1) This paragraph applies to 

research laboratories and 

production facilities engaged in the 

culture, production, concentration, 

experimentation, and manipulation 

of HIV and HBV. It does not apply 

to clinical or diagnostic laboratories 

engaged solely in the analysis of 

blood, tissues, or organs. These 

requirements apply in addition to 

the other requirements of the 

standard. 

(e)(2) Research laboratories and 

production facilities shall meet the 

following criteria: 

(e)(2)(i) Standard Microbiological 

Practices. All regulated waste shall 

either be incinerated or 

decontaminated by a method such as 

autoclaving known to effectively destroy 

bloodborne pathogens. 

(e)(2)(ii) Special Practices 

(e)(2)(ii)(A) Laboratory doors shall be kept 

closed when work involving HIV or HBV 

is in progress. 

(e)(2)(ii)(B) Contaminated materials that 

are to be decontaminated at a site away 

from the work area shall be placed in a 

durable, leakproof, labeled or color-coded 

container that is closed before being 

removed from the work area.

(e)(2)(ii)(C) Access to the work area shall be limited to authorized persons. Written policies and 

procedures shall be established whereby only persons who have been advised of the potential 

biohazard, who meet any specific entry requirements, and who comply with all entry and exit 

procedures shall be allowed to enter the work areas and animal rooms. 

(e)(2)(ii)(D) When other potentially infectious materials or infected animals are present in the work 

area or containment module, a hazard warning sign incorporating the universal biohazard symbol shall 

be posted on all access doors. The hazard warning sign shall comply with paragraph (g)(1)(ii) of this 

standard. 

(e)(2)(ii)(E) All activities involving other potentially infectious materials shall be conducted in 

biological safety cabinets or other physical-containment devices within the containment module. No 

work with these other potentially infectious materials shall be conducted on the open bench 

(e)(2)(ii)(F) Laboratory coats, gowns, smocks, uniforms, or other appropriate protective clothing shall 

be used in the work area and animal rooms. Protective clothing shall not be worn outside of the work 

area and shall be decontaminated before being laundered. 

(e)(2)(ii)(G) Special care shall be taken to avoid skin contact with other potentially infectious 

materials. Gloves shall be worn when handling infected animals and when making hand contact with 

other potentially infectious materials is unavoidable. 

(e)(2)(ii)(H) Before disposal all waste from work areas and from animal rooms shall either be 

incinerated or decontaminated by a method such as autoclaving known to effectively destroy 

bloodborne pathogens. 

(e)(2)(ii)(I) Vacuum lines shall be protected with liquid disinfectant traps and high-efficiency 

particulate air (HEPA) filters or filters of equivalent or superior efficiency and which are checked 

routinely and maintained or replaced as necessary. 

(e)(2)(ii)(J) Hypodermic needles and syringes shall be used only for parenteral injection and 

aspiration of fluids from laboratory animals and diaphragm bottles. Only needle-locking syringes or 

disposable syringe-needle units (i.e., the needle is integral to the syringe) shall be used for the 

injection or aspiration of other potentially infectious materials. Extreme caution shall be used when 

handling needles and syringes. A needle shall not be bent, sheared, replaced in the sheath or guard, or 

removed from the syringe following use. The needle and syringe shall be promptly placed in a 

puncture-resistant container and autoclaved or decontaminated before reuse or disposal. 

(e)(2)(ii)(K) All spills shall be immediately contained and cleaned up by appropriate professional staff 

or others properly trained and equipped to work with potentially concentrated infectious materials. 

(e)(2)(ii)(L) A spill or accident that results in an exposure incident shall be immediately reported to 

the laboratory director or other responsible person. 

(e)(2)(ii)(M) A biosafety manual shall be prepared or adopted and periodically reviewed and updated 

at least annually or more often if necessary. Personnel shall be advised of potential hazards, shall be 

required to read instructions on practices and procedures, and shall be required to follow them. 

(e)(2)(iii) Containment Equipment. 

(e)(2)(iii)(A) Certified biological safety cabinets (Class I, II, or III) or other appropriate combinations 

of personal protection or physical containment devices, such as special protective clothing, respirators, 

centrifuge safety cups, sealed centrifuge rotors, and containment caging for animals, shall be used for 

all activities with other potentially infectious materials that pose a threat of exposure to droplets, 

splashes, spills, or aerosols. 

(e)(2)(iii)(B) Biological safety cabinets shall be certified when installed, whenever they are moved 

and at least annually. 

(e)(3) HIV and HBV research laboratories shall meet the following criteria: 

(e)(3)(i) Each laboratory shall contain a facility for hand washing and an eye wash facility which is 

readily available within the work area. 

(e)(3)(ii) An autoclave for decontamination of regulated waste shall be available.

(e)(4) HIV and HBV production facilities shall meet the following criteria: 

(e)(4)(i) The work areas shall be separated from areas that are open to unrestricted traffic flow within 

the building. Passage through two sets of doors shall be the basic requirement for entry into the work 

area from access corridors or other contiguous areas. Physical separation of the high-containment 

work area from access corridors or other areas or activities may also be provided by a double-doored 

clothes-change room (showers may be included), airlock, or other access facility that requires passing 

through two sets of doors before entering the work area. 

(e)(4)(ii) The surfaces of doors, walls, floors and ceilings in the work area shall be water resistant so 

that they can be easily cleaned. Penetrations in these surfaces shall be sealed or capable of being 

sealed to facilitate decontamination. 

(e)(4)(iii) Each work area shall contain a sink for washing hands and a readily available eye wash 

facility. The sink shall be foot, elbow, or automatically operated and shall be located near the exit door 

of the work area. 

(e)(4)(iv) Access doors to the work area or containment module shall be self-closing. 

(e)(4)(v) An autoclave for decontamination of regulated waste shall be available within or as near as 

possible to the work area. 

(e)(4)(vi) A ducted exhaust-air ventilation system shall be provided. This system shall create 

directional airflow that draws air into the work area through the entry area. The exhaust air shall not 

be recirculated to any other area of the building, shall be discharged to the outside, and shall be 

dispersed away from occupied areas and air intakes. The proper direction of the airflow shall be 

verified (i.e., into the work area). 

(e)(5) Training Requirements. Additional training requirements for employees in HIV and HBV 

research laboratories and HIV and HBV production facilities are specified in paragraph (g)(2)(ix). 

(f) Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up. 

(f)(1) General. 

(f)(1)(i) The employer shall make available the hepatitis B vaccine and vaccination series to all 

employees who have occupational exposure, and post-exposure evaluation and follow-up to all 

employees who have had an exposure incident. 

(f)(1)(ii) The employer shall ensure that all medical evaluations and procedures including the hepatitis 

B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis, 

are: 

(f)(1)(ii)(A) Made available at no cost to the employee; 

(f)(1)(ii)(B) Made available to the employee at a reasonable time and place; 

(f)(1)(ii)(C) Performed by or under the supervision of a licensed physician or by or under the 

supervision of another licensed healthcare professional; and 

(f)(1)(ii)(D) Provided according to recommendations of the U.S. Public Health Service current at the 

time these evaluations and procedures take place, except as specified by this paragraph (f). 

(f)(1)(iii) The employer shall ensure that all laboratory tests are conducted by an accredited laboratory 

at no cost to the employee. 

(f)(2) Hepatitis B Vaccination. 

(f)(2)(i) Hepatitis B vaccination shall be made available after the employee has received the training 

required in paragraph (g)(2)(vii)(I) and within 10 working days of initial assignment to all employees 

who have 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. 

(f)(2)(ii) The employer shall not make participation in a prescreening program a prerequisite for 

receiving hepatitis B vaccination.

(f)(2)(iii) If the employee initially declines hepatitis B vaccination but at a later date while still 

covered under the standard decides to accept the vaccination, the employer shall make available 

hepatitis B vaccination at that time. 

(f)(2)(iv) The employer shall assure that employees who decline to accept hepatitis B vaccination 

offered by the employer sign the statement in Appendix A. 

(f)(2)(v) If a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public Health 

Service at a future date, such booster dose(s) shall be made available in accordance with section 

(f)(1)(ii). 

(f)(3) Post-exposure Evaluation and Follow-up. Following a report of an exposure incident, the 

employer shall make immediately available to the exposed employee a confidential medical 

evaluation and follow-up, including at least the following elements: 

(f)(3)(i) Documentation of the route(s) of exposure, and the circumstances under which the exposure 

incident occurred; 

(f)(3)(ii) Identification and documentation of the source individual, unless the employer can establish 

that identification is infeasible or prohibited by state or local law; 

(f)(3)(ii)(A) The source individual's blood shall be tested as soon as feasible and after consent is 

obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the employer shall 

establish that legally required consent cannot be obtained. When the source individual's consent is not 

required by law, the source individual's blood, if available, shall be tested and the results documented. 

(f)(3)(ii)(B) When the source individual is already known to be infected with HBV or HIV, testing for 

the source individual's known HBV or HIV status need not be repeated. 

(f)(3)(ii)(C) Results of the source individual's testing shall be made available to the exposed 

employee, and the employee shall be informed of applicable laws and regulations concerning 

disclosure of the identity and infectious status of the source individual. 

(f)(3)(iii) Collection and testing of blood for HBV and HIV serological status; 

(f)(3)(iii)(A) The exposed employee's blood shall be collected as soon as feasible and tested after 

consent is obtained. 

(f)(3)(iii)(B) If the employee consents to baseline blood collection, but does not give consent at that 

time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of 

the exposure incident, the employee elects to have the baseline sample tested, such testing shall be 

done as soon as feasible. 

(f)(3)(iv) Post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public 

Health Service; 

(f)(3)(v) Counseling; and 

(f)(3)(vi) Evaluation of reported illnesses. 

(f)(4) Information Provided to the Healthcare Professional. 

(f)(4)(i) The employer shall ensure that the healthcare professional responsible for the employee's 

Hepatitis B vaccination is provided a copy of this regulation. 

(f)(4)(ii) The employer shall ensure that the healthcare professional evaluating an employee after an 

exposure incident is provided the following information: 

(f)(4)(ii)(A) A copy of this regulation; 

(f)(4)(ii)(B) A description of the exposed employee's duties as they relate to the exposure incident; 

(f)(4)(ii)(C) Documentation of the route(s) of exposure and circumstances under which exposure 

occurred; 

(f)(4)(ii)(D) Results of the source individual's blood testing, if available; and 

(f)(4)(ii)(E) All medical records relevant to the appropriate treatment of the employee including 

vaccination status which are the employer's responsibility to maintain.

(f)(5) Healthcare Professional's Written Opinion. The employer shall 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. 

(f)(5)(i) The healthcare professional's written opinion for Hepatitis B vaccination shall be limited to 

whether Hepatitis B vaccination is indicated for an employee, and if the employee has received such 

vaccination. 

(f)(5)(ii) The healthcare professional's written opinion for post-exposure evaluation and follow-up 

shall be limited to the following information: 

(f)(5)(ii)(A) That the employee has been informed of the results of the evaluation; and 

(f)(5)(ii)(B) That the employee has been told about any medical conditions resulting from exposure to 

blood or other potentially infectious materials which require further evaluation or treatment. 

(f)(5)(iii) All other findings or diagnoses shall remain confidential and shall not be included in the 

written report. 

(f)(6) Medical Recordkeeping. Medical records required by this standard shall be maintained in 

accordance with paragraph (h)(1) of this section. 

(g) Communication of Hazards to Employees. 

(g)(1) Labels and Signs. 

(g)(1)(i) Labels. 

(g)(1)(i)(A) Warning labels shall be affixed to containers of regulated waste, 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, except as provided in paragraph (g)(1)(i)(E), (F) 

and (G).

Bloodborne Pathogens Exposure Control Plan - Oakland University

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