Written Program : Bloodborne Pathogens Plan, Opt.3

Sample Policy Statement

This is a sample policy statement provided only as a guide to assist in complying with 29 CFR 1910.1030, OSHA's Bloodborne Pathogens standard, when employee has been trained in first aid and has been designated as a first aid provider (works at first aid station, clinic or dispensary and expected to render first aid in the course of their work.)

This material and safety and health consultation services are provided at no cost to owners, proprietors, and managers of small businesses by the Illinois Onsite Safety & Health Consultation Program, Industrial Services Division, Department of Commerce and Community Affairs under a program funded largely by the Occupational Safety and Health Administration (OSHA), an agency of the U.S. Department of Labor.

ONSITE SAFETY & HEALTH CONSULTATION PROGRAM
Illinois Department of Commerce & Community Affairs
Industrial Services Division
100 West Randolph, Suites 3-400
Chicago, Illinois 60601
Phone: 312-814-2337 Fax: 312-814-7238 TDD: 800-419-0667

EXPOSURE CONTROL PLAN - TABLE OF CONTENTS

A. Policy
B. Exposure Determination
C. Exposure Control Plan

1. Exposure Control Plan (ECP)

2. Engineering Controls and Work Practices

3. Housekeeping

D. Personal Protective Equipment (PPE)
E. Training
F. Hepatitis B Vaccination
G. Reporting/Documenting & Post Exposure Evaluation

1. Procedure

2. Evaluation

3. Written Opinion

H. Laundry
I. Labeling
J. Recordkeeping

1. Medical Records

2. Training

3. OSHA Records

4. Transfer of Records

Appendix
First Aid/CPR Responders
Custodial Worker
Employee Training Record
Statement of Declination

A. POLICY. The following Exposure Control Plan (ECP) to eliminate or minimize employees occupational exposure to bloodborne pathogens.

B. EXPOSURE DETERMINATION. Employees trained as first aid/CPR providers, may have occupational exposure when rendering emergency treatment; custodians who are required to clean up the emergency site may have occupational exposure . Employees are designated as responsible for rendering first aid or medical assistance as part of their job duties. A list of the tasks and procedures in which occupational exposure may occur for these individual is attached. All exposure determinations were made without regard to the use of personal protective equipment.

C. EXPOSURE CONTROL PLAN. Employees will use Universal Precautions when providing first aid or CPR or completing clean up duties. Universal Precautions is an infection control method which requires employees to assume that all human blood and specified human body fluids are infectious for HIV, HBV and other bloodborne pathogens and must be treated accordingly. Universal Precautions are listed on the exposure determination form attached.

1. Exposure Control Plan (ECP) . Employees covered by the Bloodborne Pathogens Standard will receive an explanation of this plan during their initial training and will have an opportunity to review this plan or obtain a copy at any time during their work shifts. The ECP will be reviewed and updated annually or sooner if necessary to reflect any new or modified tasks and procedures that will affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

2. Engineering Controls and Work Practices . Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls we will use include:

Readily accessible hand washing facilities are provided in each restroom.

Employees are required to wash hands immediately or as soon as feasible after removal of gloves used to render first aid and CPR.

Interim hand washing measures, such as antiseptic towelettes and paper towels are provided for immediate use. Employees can later wash their hands with soap and water as soon as feasible.

Employees are required to wash body parts as soon as possible after skin contact with blood or other potentially infectious materials.

Red bags are provided for equipment disposal (equipment will not be decontaminated or reused).

3. Housekeeping . The custodian will be responsible for cleaning and decontaminating work surfaces following emergency treatment, if required. Normal custodian duties involving disposal of waste that may contain used personal products (sanitary napkins, band aides) is not covered under this program.

Decontaminate work surfaces with an appropriate disinfectant (1 part household bleach and 10 parts water) after completion of procedures, after any spill of blood or other potentially infectious materials.

Always use mechanical means such as tong, forceps, or a brush and a dust pan to pick up contaminated broken glassware; never pick up with hands even if gloves are worn.

Discard all regulated waste in the red bags provided, i.e., liquid or semi-liquid blood or other potentially infectious material; items contaminated with blood other potentially infectious materials that would release these substances in a liquid or semi-liquid state if compressed; items caked with dried blood or other potentially infectious materials and capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

D. PERSONAL PROTECTIVE EQUIPMENT (PPE). Personal protective equipment must be used when rendering first aid and CPR or when doing cleanup of accident site. Repair and/or replacement and maintenance of PPE will be at no cost to employees.

Training will be provided in the use of the appropriate personal protective equipment for employees' specific job classifications and tasks/procedures they will perform. Additional training will be provided, whenever necessary, such as if an employee takes a new position or if new duties are added to their current position.

Appropriate personal protective equipment is required for the following tasks; the specific equipment to be used is listed after the task:

Task	Equipment	General Precautions
First Aid	Eye Protection Disposable gloves Disposable face mask Eye protection Disposable gloves Resuscitation mouthpiece Utility gloves	Wear eye, face protection such as a mask with glasses with solid side shields or a chin-length face shield and hand protection when it can be reasonably anticipated that you may have contact with blood or other potentially infectious materials and when handling or touching contaminated items or surfaces. Wash hands immediately or as soon as feasible after removal of gloves or other personal protective equipment. Following any contact of body areas with blood or any other infectious materials, wash hands and any other exposed skin with soap and water as soon as possible. Flush exposed mucous membranes (eyes, mouth, etc.) with water. Remove protective equipment before leaving the work area if the equipment becomes contaminated. Place used protective equipment in the red bags provided for washed, decontamination, or when being discarded. Replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised. Utility gloves may be decontaminated (washing with bleach:water) for reuse if their integrity is not compromised. Discard utility gloves when they show signs of cracking, peeling, tearing, puncturing, or deterioration. Never wash or decontaminate disposable gloves for reuse or before disposal. If clothing is penetrated by blood and other potentially infectious materials, remove clothing immediately or as soon as feasible and place in red bag for laundry.
CPR
Custodian

E. TRAINING. All employees who have or are reasonably anticipated to have occupational exposure to bloodborne pathogens will receive training to cover the epidemiology and symptoms of bloodborne pathogens and modes of transmission.

This training will be augmented by in-house training on the company ECP. The supervisor will provide training to employees regarding our in-house procedures that includes the following elements.

A copy and explanation of the standard

Our Exposure Control Plan and how to obtain a copy

Methods to recognize exposure tasks and other activities that may involve exposure to blood

Use and limitations of Engineering Controls, Work Practices, and PPE

PPE - basis for selection, types, use, location, removal, handling, decontamination, and disposal

Hepatitis B Vaccine - offered free of charge. Training will be given prior to vaccination on its safety, effectiveness, benefits, and method of administration. (See Appendix O)

Emergency procedures - for blood and other potentially infectious materials

Exposure incident procedures

Post-exposure evaluation and follow-up

Signs and labels - and/or color coding

All training will be interactive, giving employees an opportunity to ask questions and receive answers. An Employee Education and Training Record will be maintained for each employee upon completion of training.

F. HEPATITIS B VACCINATION. Employees will be provided information on Hepatitis B vaccinations addressing its safety, benefits, methods of administration and availability.

The employee will be sent to the company physician after the employee agrees to accept the vaccination. The physician will establish a medical record, evaluate employee for contraindications to vaccination or prior immunity, will vaccinate employee or discuss contraindications will employee. The physician will provide us a copy of his written opinion (e.g., whether vaccine is indicated and whether vaccine was received). We will provide the employee a copy of this written opinion within 15 days.

All employees are strongly encouraged to receive the Hepatitis B vaccination series. Any employee who declines the HB vaccination is required to a declination statement to this effect (see appendix). Documentation of refusal of the HB vaccination will be kept with the employees other medical records.

Employees who initially decline the vaccine may request and obtain the vaccination at a later date at no cost.

G. REPORTING/DOCUMENTING & POST EXPOSURE EVALUATION. Should an accident occur where the employee rendered emergency treatment, the employee is to contact the supervisor immediately and in all cases before the end of the shift. If the accident involved the presence of blood or other potentially infectious materials, the employee will be offered the HB vaccination series and the emergency treatment incident will be documented on an accident report whether or not the employee was involved with an "exposure incident".

The supervisor will review the circumstances of the exposure incident to determine if procedures, protocols, and/or training need to be revised.

1. Procedure . A medical evaluation of an employee will be provided and a written opinion requested from the physician. This ensures that we are provided with documentation that a medical assessment of the employee's ability to receive the hepatitis B vaccination was completed as well as informing us regarding the employee's hepatitis B vaccination status.

We will ensure that the physician responsible for employee's HB vaccination and post-exposure evaluation and follow-up be given a copy of the OSHA Bloodborne Standard; job description of employee; incident report describing routes and circumstances of exposure; source individual's identity and HBV/HIV status if known; and employee's HBV status.

2. Evaluation . If a determination is made that the first aid provider was involved in an "exposure incident", the employee will be sent for evaluation. The physician will evaluate the exposure incident; arrange for testing of employee and source individual (if not already known); notify employee of results of all testing; provide counseling; provide post-exposure prophylaxis and evaluate any reported illness.

3. Written Opinion . The physician will provide us a copy of his written opinion that is limited to:

To whether the employee requires or has received the HB vaccination (for HB vaccinations).

To whether or not the employee has been informed of the results of the medical evaluation and any medical conditions which may require further evaluation and treatment (for post-exposure evaluation and follow-up).

We will provide the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation.

H. LAUNDRY. If clothing has been contaminated with regulated waste, remove and place in a red bag. We will send the contaminated clothing out for cleaning at no cost to the employee.

I. LABELING. Red bags will be provided and used at our facility. Red bags will be used to dispose of non-reusable equipment or will be used to contain contaminated clothing. Disposal will be handled by a licensed waste hauler.

J. RECORDKEEPING. Employee medical, training and accident/incident records will be maintained at our facility. Employees will be provided these records upon request of the employee or to anyone having written consent of the employee within 15 working days.

1. Medical Records . Medical records are maintained for each employee with occupational exposure. These records will be maintained for the period of employment, plus thirty years and will include:

The name and social security number of employee;

A copy of the employee's Hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination;

A copy of all results of examinations, medical testing, and follow-up procedures as required by the standard;

A copy of all health care professional's written opinions as required by the standard

All employee medical records are kept confidential and will not be disclosed or reported without the employee's express written consent to any person within or outside the workplace.

2. Training . The training records will be maintained (see appendix). The contents or summary of the training sessions are included as part of the written plan. Training records will be maintained for a minimum of three years from the date on which the training occurred.

3. OSHA Records . An OSHA 200 Form and 101 or equivalent will be maintained and retained for five years. Events will be documented as an injury if documentation is required.

4. Transfer of Records . If we cease to do business and there is no successive employer to receive and retain the records for the prescribed period, the employer shall notify the OSHA Director or the National Institute for Occupational Safety and Health (NIOSH) at least three months prior to scheduled record disposal and prepare to transmit them to the Director.

FIRST AID/CPR RESPONDERS

JOB CLASSIFICATION	WORK TASK	EXPOSURE SITUATION	SAFE WORK PROCEDURES (UNIVERSAL PRECAUTIONS)
Designated First Aid\CPR Responders	First-aid on accident victims or those experiencing medical difficulties.	Contact with blood, other bodily fluids.	1. Gloves must be worn by Designated First Aid/CPR Responders whenever they anticipate touching blood, bodily fluids, mucous membranes, or non-intact skin while they provide first aid or CPR procedure. 2. Gloves must be worn when handling items or surfaces obviously contaminated with blood or bodily fluids. 3. Hands and other skin surfaces should be washed immediately and thoroughly with water and antiseptic cleanser if contaminated with blood or other bodily fluids. 4. Hands should be immediately washed after gloves are removed. 5. Employees must take precautions to prevent injuries caused by needles, syringes and other sharp objects. 6. Mouthpieces, resuscitation bags, or other ventilation devices should be available to those employees who may reasonably be expected to perform CPR. 7. Clothing which becomes contaminated with blood or other bodily fluids during responses should be removed immediately (or as soon as possible) and separated from other clothing until properly laundered. 8. Areas and equipment which become contaminated with blood or other bodily fluids should be cleaned immediately with a bleach solution (1:10 to 1:100 dilution of household bleach).
	Performing Cardio-Pulmonary Resuscitation on patients.	Contact with saliva, open sores in and around mouth, and other bodily fluids.

JOB CLASSIFICATION	WORK TASK	EXPOSURE SITUATION	SAFE WORK PROCEDURES
Custodian	Cleaning sinks, toilets, other bathroom fixtures.	Contact with blood and other bodily fluids.	1. Gloves must be worn by employees whenever they anticipate touching blood, bodily fluids, and mucous membranes while they conduct their operations. 2. Gloves must be worn when handling items or surfaces obviously contaminated with blood or bodily fluids. 3. Hands and other skin surfaces should be washed immediately and thoroughly with water and antiseptic cleanser if contaminated with blood or other bodily fluids. 4. Hands should be immediately washed after gloves are removed. 5. Employees should wear eye protection whenever they are cleaning toilets, sinks, or other facilities. 6. Employees must take precautions to prevent injuries caused by needles, syringes and other sharp objects. 7. Clothing which becomes contaminated with blood or other bodily fluids during custodial activities should be removed immediately (or as soon as possible) and separated from other clothing until properly laundered. 8. Areas and equipment which become contaminated with blood or other bodily fluids should be cleaned immediately with a bleach solution (1:10 to 1:100 dilution of household bleach).
	Clean-up of vomit, other bodily fluids.	Contact with potentially infectious fluids and materials.
	Removal of waste.	Contact with feminine sanitary items and other potentially contaminated materials. Handling disposed syringe needles and other potentially contaminated sharps.
	General site clean-up.	Contact with disposed syringe needles, disposed personal items, and other potentially infectious materials.

BLOODBORNE PATHOGENS PROGRAM EMPLOYEE TRAINING RECORD

Trainer Names & Qualifications:

Employee's Name & Job Title	Date Trained	Employee Signature	Date of Annual Refresher Training

STATEMENT OF DECLINATION OF HEPATITUS B VACCINATION

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

Signature:_____________________ Date:_________________

Blood Borne Pathogens Plan, opt.1
Blood Borne Pathogens Plan, opt.2
Blood Borne Pathogens Exposure Control Plan, opt 4