Bloodborne Pathogens

OSHA (29 CFR 1910.1030)


The purpose of this plan is to inform interested persons, including employees, that the University of Saint Francis is complying with the Occupational Safety & Health Administration Confined Space Standard, Title 29 Code of Federal Regulations 1910.1030 to protect employees from the hazards of exposure to blood or other potentially infectious materials (OPIM). Any worker, including full-time, part-time, contract, temporary and per diem, who has reasonably anticipated contact with blood or OPIM during performance of his/her job is considered to have occupational exposure to bloodborne pathogens including Hepatitis B. Employees determined to have occupational exposure must comply with the procedures outlined in this plan. This plan does not cover “good Samaritan” assistance given to or by co-workers.

In summary, the university has established this Exposure Control Plan including exposure determination, exposure precautions and controls, communication, training and recordkeeping. In addition, known exposure incidents to Hepatitis B must be evaluated and receive follow-up.


Occupational Exposure means, with the exception of “fixed specimens” such as cadavers, reasonably anticipated contact with human blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, unknown body fluid, internal tissue or organ with one’s skin, eye, or mucous membrane.


The Risk and Safety Management Committee is responsible for review of the OSHA Bloodborne Pathogen Standard, implementation of the Exposure Control Plan, and maintaining, reviewing, and updating the plan at least annually, including new or modified tasks and procedures, aiming to further reduce exposure through incorporation of new technologies. Incident reports from the Director of Security and supplier information for new products provided by the Director of Operations will assist in evaluation of procedures and technologies. The Committee will also ensure the plan is readily available to all covered employees during their work shift.

The department head or supervisor of each affected department will maintain and provide all necessary and appropriate personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and biohazard containers as required by the standard and be responsible for training and documentation of training.

The Director of Human Resources is responsible for making exposure determinations and ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained, including Hepatitis B vaccination records.

Exposure Determination
The Director of Human Resources will evaluate the work force to identify the job classifications in which employees have the potential for occupational exposure to blood or other potentially infectious material (OPIM) during the course of their assigned duties. The following determinations have been made for the university:

  • Security officers – All officers are designated first responders in emergency situations.
  • Athletic department – All trainers, coaches and assistants who treat injuries and administer first aid. All personnel who are responsible for handling laundry that contains blood or OPIM. All weight room staff who disinfect equipment.
  • Custodial – All custodial staff who clean restrooms or dorm rooms.
  • Maintenance – All maintenance staff who repair restroom facilities.
  • Resident Hall Directors – All resident hall directors whose daily activities include potential contact with students, and assistance in times of duress.
  • Faculty – Any faculty who handle “unfixed” medical or biohazard waste or may
    administer shots or vaccinations (i.e. at Focus on Health event).
  • Laboratory staff – Any laboratory staff who handle “unfixed” medical or biohazard
    waste. The above determinations have been made without regard to the use of personal protective equipment.

Methods of Implementation, Control and Compliance
Universal precautions, work practice controls and engineering controls will be in place to prevent contact with blood or OPIM, all of which shall be considered to be infectious regardless of the perceived status of the source individual.

Hand washing facilities are readily accessible across campus. Employees shall not leave the athletic training rooms, health or science laboratories, restrooms, or any other area after potentially contacting blood or OPIM until washing their hands and other potentially contaminated skin areas with soap and running water. Eating, drinking, smoking, applying cosmetics, lip balm or handling contact lenses is prohibited in areas where there is a reasonable likelihood of exposure. Food or drink shall not be placed near potentially infectious materials (refrigerators, freezers, cabinets, countertops, etc.).

Appropriate containers shall be provided for the collection of contaminated materials. Contaminated sharps shall not be purposely broken; needles shall not be bent, recapped or removed.

When there is the possibility of occupational exposure, the university will supply, at no cost to the employee, appropriate personal protective equipment (PPE) such as, but not limited to, gloves, gowns, lab coats, face shields or goggles. The university is responsible for replacing disposable and worn equipment. The department supervisor will be responsible for providing the PPE. PPE will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees’ clothing, skin, eyes or mouth under normal conditions of use and for the duration of time for which the equipment will be used. Employees should 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; and 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. Where PPE is mandated, the employee may decline its use under rare and extraordinary circumstances only, for example, if the use of PPE would have increased the hazard to the worker or co-worker. Each incident of such shall be investigated and documented.
Each employee using PPE must observe the following precautions:

  • Replace gloves if torn, punctured, contaminated, or if their ability to function as a
    barrier is compromised.
  • Remove PPE after it becomes contaminated, and before leaving the work area.
  • 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.
  • Wash hands immediately or as soon as feasible after removal of gloves.
  • 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.

Injuries that pose an exposure risk shall be reported to the Director of Safety and Security immediately. The Director of Safety and Security will document the incident and transfer the information to the Director of Human Resources. The Director of Human Resources will maintain a sharps injury log identifying the type and brand of device, the department or work area of the incident and an explanation of the occurrence.


The university will maintain a clean and sanitary working environment. Where blood or OPIM are present, surfaces shall be decontaminated as soon as feasibly possible after the event or work is complete. This is the responsibility of the individual completing the work or responding to the event.
Broken glassware that may be contaminated is picked up using mechanical means, such as a brush and dust pan. This material and all other contaminated sharps will be placed in closable, puncture resistant, leakproof on the sides and bottom, labeled containers. These containers will not be overfilled and will be closed prior to moving.

Other regulated (non-sharps) medical or biohazard waste is placed in containers that prevent leakage, are appropriately labeled, not overfilled, and closed prior to removal to prevent spillage or protrusion of contents during handling.

Leaking containers shall be placed in a secondary container leak-proof on the sides and bottom. The laboratory assistant/manager for the work area is responsible for monitoring containers and contacting the Director of Safety & Security in the event of a leaking or full container that needs disposed.

Biohazard and sharps containers from across campus (i.e. athletics, health sciences) will be consolidated at Achatz Hall room 15 in the large bio-hazard containers prior to disposal. The Director of Safety and Security oversees the transfer of these containers from various buildings to Achatz and removal of these containers from the campus at the end of each semester by Healthcare Waste Management.

Contaminated laundry should be bagged at the location of use and transferred to laundry machines with minimal agitation. Personnel handling contaminated laundry should wear gloves.

Hepatitis B

All employees who have been identified as having occupational exposure to blood or OPIM will be offered the Hepatitis B vaccination through a licensed healthcare professional, at no cost to the employee within 10 days of initial assignment with possible exposure unless the employee has received the complete series, is immune or otherwise medically unadvised. Employees who choose to decline the vaccination will sign a waiver, but later may receive the vaccination at no cost the employee.
When an employee has an exposure incident it must be reported to the Director of Human Resources for a post exposure evaluation and follow up in accordance with OSHA standards. This will include the following:

  • Documentation of the route of exposure and circumstances related to the incident.
  • Identification of the source individual and determination for HIV/HBV infection.
  •  Test results will be available to exposed employee with information about laws and  regulations concerning disclosure of identity and infectivity of source individual.
  • The exposed employee’s blood will be collected as soon as feasible after consent is obtained. If consent is given to baseline collecting but not HIV testing the sample will be preserved for at least 90 days. If, within 90 days the employee decides to have the baseline sample tested, the testing will be done as soon as feasible.
  • Employee will be offered treatment, as medically indicated, counseling and evaluation of reported illness. The university will provide to the healthcare professional the employee’s duties and circumstances during the event, route of exposure, employees vaccination and other medical records on file, and HIV/HBV determination of the source. The healthcare professional must provide a written opinion within 15 days including their communication with the employee on the results of the evaluation and potential medical conditions that may result.
  • The Director of Human Resources will maintain the records related to exposure incidents.


Warning labels on containers housing potentially infectious materials are the primary form of
communication. The biological hazard symbol    shall be imprinted on containers (i.e. rigid sharps containers or fiberboard boxes). Additionally, containers may have orange or red markings or incorporate the word “Biohazard”. Decontaminated (i.e. autoclaved) waste will not show the icon or utilize red or orange packaging.


Confidential medical records are maintained by the Director of Human Resources for each employee in accordance with 29 CFR 1910.1020, “Access to Employee Exposure and Medical Records” for at least the duration of employment plus 30 years. In compliance with Bloodborne Pathogens regulations the medical record will include

  • Employees name and social security number
  • Copy of hepatitis B vaccination series or waiver
  • Copy information supplied to the healthcare provided following exposure
  • Examination, testing, follow-up, healthcare professional’s written opinion, after an  exposure

Injuries that pose an exposure risk shall be kept on record for at least the duration of employment plus 30 years. USF, as an educational service, is exempt from maintaining a sharps injury log (per OSHA publication 3169).
Training records are completed for each employee upon completion of bloodborne pathogen training. These documents will be kept for three years.
Copies of employee medical, injury or training records related to the Bloodborne Pathogen Exposure Control Plan may be requested in writing to the Director of Human Resources and will be provided within 15 working days.

Each employee who has occupational exposure to bloodborne pathogens shall receive training at the initiation of the assignment and then annually thereafter during regular working hours at no cost to the employee. Annual retraining must be within one year of the previous training. Training shall include:

  • access to the regulations and explanation of its contents.
  • a general explanation of the symptoms of bloodborne diseases.
  • an explanation of the modes of transmission of bloodborne pathogens.
  • an explanation of the employers’ exposure control plan and how to obtain a copy.
  • an explanation of the methods for recognizing tasks and activities that may involve exposure to bloodborne pathogens.
  • an explanation of the use and limitations of methods that will prevent or reduce exposure including engineering controls, work practices and personal protective equipment.
  • information of the types, proper use, location, removal, handling and  decontamination and disposal of personal protective equipment.
  • an explanation of the basis for selection of personal protective equipment.
  • information on the hepatitis B vaccine, including information on its efficacy, safety,  method of administration, the benefits of being vaccinated and that the vaccine and  vaccination will be 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 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 the employer is required to provide for the employee following an exposure incident.
  •  an explanation of the labels.
  • an opportunity for interactive questions and answers with the person conducting the training.


Contractors are not covered by this Plan and shall follow the Exposure Control Plan established by their company.


Approved  6/6/2012
Reviewed 10/9/2013
Risk and Safety Management Committee