Bloodborne Pathogen Exposure Policy

Purpose and Application

This policy is written to minimize all exposures to blood and other potentially infectious material.

This policy applies to employees who may reasonably anticipate occupational exposure to bloodborne pathogens.

This policy ensures that training and the hepatitis B vaccination series are made available to those individuals who are exposed to bloodborne pathogens (BBP) in the course of their duties.

Definition and Scope

“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 including hepatitis B virus (HBV) hepatitis C virus (HCV) and human immunodeficiency virus (HIV).

“Occupational exposure” means reasonably anticipated skin, eye, mucous membrane, or potential contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.

“Other potentially infectious materials” (OPIM) includes, but is not limited to, the following: human bodily fluids, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, amniotic fluid, saliva in dental procedures; any mix of body fluids where it is impossible to differentiate between fluids; any unfixed human tissue or organ.

Roles and Responsibilities

The Environmental Health and Safety (EHS) department assists in providing information and training on safe work practices, conducts routine inspections of work areas, investigates accidents, and recommends preventive/corrective actions. EHS monitors the college/university compliance with the OSHA Bloodborne Pathogen Standard.

Supervisors are responsible for ensuring annual training for any of their staff that may reasonably anticipate exposure to bloodborne pathogens in the course of performing their duties.

The custodial services, assisted by security/life safety, ensure that routine blood or OPIM spills are properly cleaned up and the area sanitized.


Written Plan
Both campuses have written Exposure Control Plans, which describe the programs in detail. These plans are updated by EHS in cooperation with other departments and safety committees.

Exposure Control
A variety of controls are in place to effectively eliminate or minimize the risks of infection, including universal precautions, engineering controls and work practices, personal protective equipment, sanitary conditions, waste regulation, laundry procedures, and labels and signs. These controls are detailed in the written plans and summarized in employee training.

Training is provided for personnel that are affected by the BBP standard. EHS provides guidance and assists with arrangements for general annual refresher. Affected departments are responsible for the site-specific training and up to date employee records.

Hepatitis B Vaccination
The hepatitis B vaccination series is available to all employees identified in the exposure control plan to have occupational exposure to bloodborne pathogen. Vaccination procedures must be coordinated through either EHS or Health Center. Any employee who declines the vaccination must sign a declination statement that will be maintained in personnel medical file.

Bloodborne Pathogen Incidents
Minor accidents, or incidents involving release of blood or other potentially infectious materials are often cleaned up voluntarily by the source of release using supplied pathogen kits. For significant releases or if the source is unidentified, trained custodial staff will respond with back up assistance from security/life safety. Any exposure to employees or students must immediately be reported by completing the appropriate bloodborne pathogen incident report form. A copy of the form must be submitted to EHS for incident analysis. This will initiate the appropriate medical evaluation. The exposed employee will seek medical evaluation from Occupational Health Clinic of her or his choice.

Record Keeping
EHS maintains training records for three years from the date of the training. Departments may maintain site-specific training records. The training records will include the dates and contents of the training sessions. The human resources maintain medical records on employees with occupational exposure to blood or other potentially infectious material.

Key References and Resources

The following references and resources may be obtained from EHS and in some cases are available on the EHS home page.