This is a sample written Exposure Control Plan provided only as a guide to assist in complying with 29 CFR 1910.1030, OSHA's Bloodborne Pathogens standard.  It is not intended to supersede the requirements detailed in the standards.  You need to review the standard for particular requirements which are applicable to your specific situation.  Note that this sample program does not include provisions for HIV/HIB laboratories and research facilities which are addressed in the standards. If you operate this type of facility, you need to include provisions as re­quired by the standard. Employers will need to delete or add information relevant to your particular facility in order to develop an effective, comprehensive exposure control plan. Note that the exposure control plan is expected to be reviewed at least on an annual basis and updated when necessary. 

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 Economic Opportunity 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 & Economic Opportunities

Industrial Services Division

100 West Randolph, Suites 3-400 Chicago, Illinois 60601

Phone:  312/814-2337    Fax: 312/814-7238    TDD:  800/419-0667

 

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

TABLE OF CONTENTS 

 

A. Exposure Determination.......................................................................................................... 3  

B. Implementation Schedule & Methodology.............................................................................. 4 

C. Hepatitis B Vaccine & Post-Exposure Evaluation & Follow-up  ...................................... 12 

D. Interaction with Health Care Professionals ......................................................................... 14 

E. Information and Training ....................................................................................................... 15 

F. Recordkeeping ...................................................................................................................... 15 

G. Dates, Evaluation and Review ............................................................................................. 17 

Appendices

Statement of Declination

Sample Exposure Incidence Report

Sample Training Outline

Sample Sharps Injury Log

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

 

FACILITY NAME: _________________________________________

 

We have developed this Exposure Control Plan (ECP) to elimin­ate or minimize employee occupational exposure to blood or other body fluids, and to comply with OSHA’s Bloodborne Pathogens standard, 29 CFR 1910.1030. Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It is also reviewed in their annual refresher training. All employees have an opportunity to review this plan at any time during their work shifts. If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request.

 

 ____________________ is the Program Administrator responsible for the implementation of the Exposure Control Plan (ECP). The Program Administrator will maintain, review and update the ECP at least annually, and whenever necessary to include new or modified tasks or procedures. The Program Administrator is also responsible for:

 

•                     Maintaining and providing all necessary personal protective equipment (PPE), engineering controls, labels and red bags.

•                     Ensuring that adequate supplies of equipment are available in the appropriate sizes.

•                     Ensuring that all new recommendations or changes are effectively implemented.

•                     Ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained.

•                     Training, documentation of training and making the written ECP available to employees, OSHA and NIOSH representatives.

•                     Recordkeeping

 

A.   Exposure Determination. Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP. The job classifications where all employees have occupational exposure are:

 

Job Title	Department/Location

           

Job classifications where some employees have occupational exposure is below. This list includes all full-time, part-time, contract and per diem employees. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals.

 

Job Classification	Department/Location	Tasks/Procedures
Example: Janitor	Example: Maintenance	Example: Handling Regulated Waste

 

B. Implementation Methods & Controls

 

1.      Universal Precautions. Universal precautions are used in order to prevent contact with blood or other potentially infectious materials (OPIM).  All blood or other potentially infectious material are considered infectious regard­less of the perceived status of the source individual.

 

2.      Engineering Controls and Work Practices. Engineering and work practice controls are used to eliminate or minimize exposure to employees at this facility. Where occupational exposure remains after institution of these controls, personal protective equipment is also used. Specific engineering controls and work practice controls used are listed.

 

 

 

  

Controls listed are examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is as follows:

 

 

 

  

 

We identify the need for changes in engineering control and work practices; we evaluate new procedures or new products regularly. Both front line workers and management officials are involved in this process.

 

     

 

  

 

Hand washing facilities are available and readily accessible to employees who incur expo­sure to blood or other potentially infectious materials. At this facility, hand washing facilities are located:

 

 

 

 

 

  

 

After removal of personal protective gloves, employees wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water. If employees incur exposure to their skin or mucous membranes then those areas are washed or flushed with water as soon as feasible following contact.

 

3.   Needles . Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. 

 

If recapping or needle removal is required, then the recapping or removal of the needle must be done by the use of a mechanical device or a one_handed technique.  At this facility recapping or removal is only permitted for the following procedures:

 

 

  

4.   Containers for Reusable Sharps . Contaminated sharps that are reusable are placed after use into appropriate sharps containers. The sharps containers are leak proof, puncture resistant and labeled with a biohazard label.

 

 

  

5.   Work Area Restrictions . Employees may not eat, drink, apply cosmetics or lip balm,

smoke, or handle contact lenses in any work area where there is a reasonable likelihood of exposure to blood or OPIM. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or OPIM are present.  

All procedures are conducted in a manner which will minimize splashing, spraying, splattering and generation of droplets of blood or other potentially infectious materials.  Methods which are employed to accomplish this goal are:  

 

 

6.   Specimens. Specimens of blood or OPIM are placed in a container which prevents leakage during the collection, handling, processing, storage and transport of the specimens. Any specimens which could puncture a primary container are placed within a secondary container which is puncture resistant.

 

  

If outside contamination of the primary container occurs, the primary container is placed within a secondary container which prevents leakage during the handling, processing, storage, transport or shipping of the specimen.

 

 

  

7.   Contaminated Equipment . Equipment which has become contaminated with blood

or other potentially infectious materials is examined prior to servicing or shipping and decontaminated as necessary unless the decontamination of the equipment is not feasible.  

  

 

8.   Personal Protective Equipment . The required personal protective equipment is

provided to employees at no cost to them. Appropriate PPE in a variety of sizes is readily accessible at the work site or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives are readily accessible to those employees who are allergic to the gloves normally provided.

 

Training in the use of PPE is provided and covers the appropriate PPE for the tasks or procedures employees perform. Types of PPE available to employees are as follows. 

 

 

 

 

 

 

 

  

 

All employees using PPE must 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 ________ (List appropriate containers for storage, laundering, decontamination or disposal).

•         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 show signs of 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 any garment contaminated by blood or OPIM in such a way as to avoid contact with the outer surface.

 

All employees are expected to use the required personal protective equipment (PPE). An employee who temporarily and briefly declines to use PPE must report to the immediate supervisor (i.e., it was the employee's professional judgment that in the specific instance its use would have prevented the delivery of healthcare or posed an increased hazard to the safety of the worker or co-worker).  When the employee makes this judgment, the supervisor will investigate and document the cir­cumstances in order to determine whether changes can be instituted to prevent such occurrences in the future.

 

All personal protective equipment is cleaned, laundered and disposed of at no cost to employees.  All repairs and replacements are made at no cost to employees.

 

All garments which are penetrated by blood must be removed immediately or as soon as feasible. All personal protective equipment must be removed prior to leaving the work area. The following protocol has been developed so that equipment is left at the work area and is not taken home.

 

  

 

 

Disposable gloves used at this facility are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised. Utility gloves are 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.

 

9.   Housekeeping. This facility is cleaned and decontaminated according to the following schedule (list area and schedule):

 

Area	Schedule	Cleaner
Example: Contaminated work surfaces	Example: After completion of procedures; immediately, or as soon as possible, after spills or OPIM; at the end of the work shift	List materials used, such as bleach solutions or EPA registered germicides
Example: Bins, pails, cans or similar receptacles	When	How
Example: Broken glassware which may be contaminated is picked up using mechanical means, such as a brush and dust pan.	When	How

 

 

  

 

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.

 

The following contaminated articles will be laundered by this facility:___________ or Laundering will be performed by ___________at ___________time/location.

 

Laundry contaminated with blood or other potentially infectious materials are handled as little as possible. The laundry is placed in appropriately marked bags at the location where it was used. The laundry will not be sorted or rinsed in the area of use.

 

 

 

  

 

 

 

 

10. Labels. The following labeling method(s) is used at this facility.

 

Equipment to be Labeled	Label type (size, color, etc.)
Example: specimens, contaminated laundry containers used to store, transport or ship blood or OPIM)	Example: red bag, biohazard label, etc.
Example: refrigerators and freezers containing blood or OPIM
Example: regulated waste or contaminated equipment brought into the facility

 

11.    Regulated Waste Disposal. Regulated waste is placed in containers which are closeable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded and closed prior to removal to prevent spillage or protrusion of contents during handling.

 

The container is placed in a secondary container if leakage of the primary container is possible.  The second container must be closeable, constructed to contain all contents and prevent leakage during handling, storage and transport, or shipping.  The second container must be labeled or color coded to identify its contents.

 

a.                   Disposable Sharps.  All contaminated sharps are discarded as soon as feasible in sharps containers which are closeable, puncture resistant, leak proof on sides and bottom and labeled or color coded.

 

During use, containers for contaminated sharps is easily accessible to personnel and located as close as possible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., laundries).  Sharps containers are located in (specify locations of sharps containers) _____________________. The containers are maintained upright throughout use and replaced routinely and are not allowed to overfill.

 

When moving containers of contaminated sharps from the area of use, the containers are closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport or shipping.  

                 Reusable containers are not to be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of percutaneous injury.

  b.       Other Regulated Waste. Regulated waste other than sharps is placed in appropriate containers. These containers are located in (specify locations of containers.) ________________________.  

The waste is to be labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport or shipping.

 

C. Hepatitis B Vaccine & Post-exposure Evaluation & Follow-up. The Hepatitis B vaccine and vaccination series are made available to all employees who have occupational exposure. Training is provided to employees on Hepatitis B vaccinations. The training addresses the safety, benefits, efficacy, methods of administration and availability.

 

1.   Hepatitis B Vaccination. The vaccine is offered after the employee has received the training in occupational exposure (see information and training) and within 10 working days of their initial assignment to work involving the potential for occupational exposure to blood or other potentially infectious materials unless the employee has previously received the complete Hepatitis B vaccination series, or antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.

 

Participation in a pre-screening program is not a prerequisite for receiving Hepatitis B vaccination.

 

Employees who decline the Hepatitis B vaccine will sign a waiver which uses the wording in Appendix A of the OSHA Standard (sample attached). Employees who initially decline the vaccine but who later (while still covered under the standard) wish to have it may then have the vaccine provided at no cost.

 

______________________________ has responsibility for assuring that the vaccine is offered, the waivers are signed, etc.  ___________________ will administer the vaccine.

 

If a routine booster dose of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster doses will be made available.

 

2.   Post Exposure Evaluation & Follow-Up. Post exposure follow-up is provided to employees who have had an exposure incident. The employee is given appropriate counseling concerning pre­cautions to take during the period after the exposure incident. The employee will also be given information on what potential illnesses to be alert for and to report any related experiences to appropriate personnel. 

 

Employees report exposure incidents to (list who has responsibility to maintain records of exposure incidents) who will review the circumstances of the exposure incident to determine:

 

•                     engineering controls in use at the time

•                     work practices followed

•                     a description of the device being used (including type and brand)

•                     protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.)

•                     location of the incident

•                     procedure being performed when the incident occurred

•                     employee’s training

 

A confidential medical evaluation and follow-up is conducted by ______HCP. Following the initial first aid (clean the wound, flush eyes or other mucous membranes, etc.), the following activities are performed.

 

•                     Document routes of exposure and the circumstances related to the incident.

•                     Identify and document the source individual unless it can be established that identification is infeasible or prohibited by state or local law.

•                     Unless already know to be infected, obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV and HBV infectivity; document that the source individual’s test results were conveyed to the employee’s health care provider.

•                     Assure that the exposed employee is provided with the source individual’s test results and with information about applicable disclosure laws and regulations concerning the identify and infectious status of the source individual.

 

Collection and testing of blood for HBV and HIV serological status will comply with the following:

 

•                     The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained.

•                     If employee does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days to allow the employee to decide if the blood should be tested for HIV serological status. If the employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.

•                     Employees are offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service. These recommendations are currently as follows: (these recommendations may be listed as an appendix to the plan)

D. Interaction with Health Care Professionals

 

l.    Information provided to the Healthcare Professional. The healthcare professional responsible for the employee's Hepatitis B vaccination is provided with the following:

 

•       A copy of 29 CFR 1910.1030.  Note: while the standard outlines the confidentiality requirements of the health care professional, it might be helpful for the employer to remind that individual of these re­quirements.

•       A written description of the exposed employee's duties as they related to the exposure incident;

•       Written documentation of the route of exposure and circumstances under which exposure occurred;

•       Results of the source individuals blood testing if available;

•       All medical records relevant to the appropriate treatment of the employee including vaccination status.

 

2.   Healthcare Professional's Written Opinion. A written opinion is obtained from the health care professional who evaluates employees of this facility.  The employee are provided with a copy of the written opinion within 15 days of the completion of the evaluation.  Written opinions are obtained in the following instances:

 

•                     When the employee is sent to obtain the Hepatitis B vaccine.

•                     Whenever the employee is sent to a health care professional following an exposure incident.

 

The healthcare professionals written opinion for HBV vaccination is limited to whether HBV vaccination is indicated for an employee and if the employee has received such vaccination.  

The healthcare professionals written opinion for post exposure follow-up is limited to a statement that the employee:

 

•                     Has been informed of the results of the evaluation, and

•                      Has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials.  (Note that the written opinion to the employer is not to reference any personal medical in­formation.)  

Note: All other findings or diagnosis will remain confidential and shall not be included in the written report.  

All medical evaluations and procedures, the Hepatitis B vaccine and vaccination series and post exposure follow-up, including prophylaxis, and laboratory test are available at no cost to employees. They are made available to employees at a reasonable time and place; performed by or under the supervision of a licensed physician or other licensed healthcare professional; and provided according to the recommendations of the U.S. Public Health Service.  

E. Information and Training  

All employees who have occupational exposure to bloodborne pathogens receive training conducted by ______________________ (attach a brief description of their qualifications if necessary). Training materials are available at ___________________. 

Training is provided at the time of initial assignment to tasks where occupational exposure may occur, and that it is repeated within twelve months of the previous training. Training includes epidemiology, symptoms and transmission of bloodborne pathogen diseases. Employees have an opportunity for interactive questions and answers with the person conducting the training sessions. In addition, the training program covers, at a minimum, the following elements. 

•                     A copy and explanation of the standard.

•                     An explanation of our ECP and how to obtain a copy.

•                     An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident.

•                     An explanation of the use and limitations of engineering controls, work practices and personal protective equipment.

•                     An explanation of the types, use, location, removal, handling, decontamination and disposal of personal protective equipment.

•                     An explanation of the basis of selection of personal protective equipment.

•                     Information on the Hepatitis B vaccination, including efficacy, safety, method of administration, benefits and that it are offered free of charge.

•                     Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.

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

•                     Information on the evaluation and follow-up required after an employ­ee exposure incident.

•                     An explanation of the signs, labels and color coding systems required by the standard and used at this facility.  

All employees will receive annual refresher training. Note that this training is to be conducted within one year of the employee's previous training. Additional training shall be provided to employees when there are any changes of tasks or procedures affecting the employee's occupational exposure.  

F. Recordkeeping  

1.   Medical Records. Medical records are maintained for each employee with occupational exposure. The Program Administrator is responsible for maintaining medical records. These confidential records are kept for at least the duration of employment plus 30 years. The records shall include the following:

 

•                     The name and social security number of the employee.

•                     A copy of the employee's HBV vaccination status, including the dates of vaccination.

•                     A copy of all results of examinations, medical testing and follow-up procedures.

•                     A copy of the information provided to the healthcare professional, including a description of the employee's duties as they related to the exposure incident, and documentation of the routes of exposure and circumstances of the exposure.

 

Medical records are provided upon request to the employee or to anyone having written consent of the employee within 15 working days. Requests should be addressed to the Program Administrator.

 

2.   Training Records. Training records are completed for each employee upon completion of training. These documents are maintained for three years. The following information shall be documented:

 

•                     The dates of the training sessions.

•                     An outline describing the material presented; the contents or a summary of the training sessions.

•                     The names and qualifications of persons conducting the training.

•                     The names and job titles of all persons attending the training sessions.

 

Training records are provided upon request to the employee or the employee’s authorized representative within 15 working days. Requests should be addressed to the Program Administrator.

 

3.      Sharps Injury Log. In addition to the 1904, recordkeeping requirements, all percutaneous injuries from contaminated sharps are also recorded on the Sharps Injury Log. All incidences must include at least the date of the injury; the type and brand of the device involved; the department or work area where the incident occurred; an explanation of how the incident occurred.

 

The log is reviewed at least annually as part of the annual evaluation of the program and is maintained for at least five years following the end of the calendar year that they cover. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

 

G. Dates, Evaluation and Review

 

All provisions required by this standard were implemented by (insert date). The Program Administrator is responsible for annually reviewing this program and its effectiveness, and for updating this program as needed.

Statement of Declination of Hepatitis 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.  

_________________________

Sample Exposure Incident Report

 

Information provided to Dr._____________________________ 

Employee Name: 

Date of exposure incident: 

Location of exposure incident:  

Route(s) of exposure:

 

Results of Source Individual’s tests if possible (unless prohibited by law):

 

 

Description of employee’s duties related to exposure incident:

 

 

 

Circumstances under which exposure occurred:

 

 

 

Results of previous blood tests:

      Test(s) conducted:

      Test date:

      Results:

 

 

Attachments:

 

1.   Employee’s medical records relevant to appropriate treatment, including vaccination status.

2.   One copy of OSHA Regulation, 1910.1030, Bloodborne Pathogens.

Sample Training Outline

 

1.   Introduction. Introduce self and other presenters as applicable. Class is designed as initial training for new employees and to satisfy annual follow-up annual training.

 

2.   List objectives of Training.

•          Describe the primary diseases that the exposure control plan covers

•          Explain modes of transmission of HBV and HIV

•          Define the term “Universal Precautions.”

•          Define the terms “engineering controls” and “work practice controls” and be familiar with those used in the workplace.

•          List personal protective equipment that may serve as effective barriers to infectious fluids.

•          Describe labeling, contaminated waste, and laundry procedures.

•          Identify the general requirements of OSHA Regulation 1910.1030, Bloodborne Pathogens.

 

3.   Program Requirements. Give an overview of basic exposure control plan elements, and where employees can obtain a copy.

 

4.   HBV and HIV. Discuss epidemiology, symptoms, and modes of transmission of HBV and HIV.

 

5.   Exposure Determination. Through question/answer discussion, have students determine those tasks that may result in an exposure incident.

 

6.   Methods of Compliance. Discuss exposure controls and work practice controls. Have students give examples of each where they work.

 

7.   Personal Protective Equipment. Show a video, or present samples of various types of personal protective equipment and how they form effective barriers to infectious fluids. Demonstrate proper wear, handling, decontamination, removal and disposal.

 

8.   Post Exposure Procedures. Explain specific emergency procedures if an exposure incident occurs. Include notification, evaluation and follow-up procedures.

 

9.   HBV Vaccine Information. Explain how effective and safe HBV vaccinations are, and the benefits of being vaccinated. Emphasize that the vaccinations are free to employees.

 

10. Question and Answer Period. Ensure an expert source is available to answer questions employees may have regarding any part of the exposure control plan or HBV/HIV disease.

 

11. Conclusion. Administer and review post-training test with students. (Tests need not be graded, but should serve as a tool to determine if a review is necessary).