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To establish guidelines that protect employees who respond to medical emergencies or deal with any materials where they may be potentially exposed to blood and/or body fluids (reference standard 29 CFR 1910.1030). This policy covers the employee’s qualification, compliance methods, vaccinations, training, and recordkeeping.

Employee Exposure Determination

The following is a list of all job classifications where all employees at our establishment have occupational exposure:

Job Title








The following is a list of job classifications where some employees at our establishment have occupational exposure:

Job Title








Engineering and Work Practice Controls

Controls should be in place to minimize or eliminate exposure (sharps disposable containers, self-sheathing needles, etc.). After use, contaminated sharps should be placed immediately, or as soon as possible, into appropriate containers. The containers should be closable, puncture-resistant, leak-proof, and labeled with a biohazard label. Contaminated needles should not be bent, recapped, removed, sheared, or intentionally broken.

All employees should wash and scrub their hands with soap and water if potential exposure exists. Handwashing facilities should be readily accessible to employees and located throughout the facility.  Handwashing should be done (at a minimum) at the beginning and the end of a shift, immediately after contact with blood or other potentially infectious materials, immediately after gloves or other personal protective equipment (PPE) removal.

In work areas where there is a reasonable likelihood or potential exposure to blood or other infectious materials, employees should not eat, drink, smoke, apply cosmetics or lip balm, handle contact lenses, or use hand lotions while working. Food and drinks should not be kept in refrigerators, freezers, shelves, cabinets, or on counters or benches where blood or other infectious materials are present.

Blood and other infectious materials specimens should be placed in a container, which prevents leakage during the collection, handling, processing, storage, and transport of the specimens. Containers should be labeled and color-coded in accordance with OSHA standards. Container must be closed prior to storage, transport, and shipping. 


Contaminated work surfaces should be decontaminated with an appropriate disinfectant immediately or as soon as feasible. An appropriate disinfectant is registered with the EPA as HIV- and HBV-effective (a solution of 5.25% sodium hypochlorite [household bleach] diluted between 1:10 and 1:100 = one cup of bleach per two gallons of water).

A blood and body fluid spill kit should be available for use in the case of a blood or other potentially infectious material spill. The kit should contain a pair of vinyl or latex gloves, two pieces of absorbent material (a cloth or paper towel), a small bucket or spray bottle, two plastic bags, and disinfectant.

If the floor or other surfaces have been contaminated with blood other potentially infectious material, the employee should do the following:

  • Put on gloves.
  • Lay out an open bag.
  • Dampen first piece of absorbent material and mop up spill.
  • Deposit material in bag. Avoid touching outside of bag.
  • If outside of bag is contaminated, put contaminated bag into second bag.
  • Dampen second piece of absorbent material and clean floor or surface. Deposit into bag.
  • Tie bag snugly.
  • Dispose of bag in common waste container.
  • Return bucket or spray bottle to storage area. Restock used items in spill kit.
  • Wash hands after removing gloves.

Regulated waste should be placed in approved properly labeled containers and disposed according to established regulatory procedures.

Laundry, including linens and reusable PPE, should be handled as little as possible and with minimum agitation. It should be bagged and put into a container. Contaminated laundry should not be sorted or rinsed in the location of use. Employees handling soiled laundry should wear disposable or utility gloves and gowns. The facility should wash contaminated laundry according to recommendations outlined by the Centers for Disease Control (wash with detergent and water at 160 degrees for 25 minutes).


PPE should be provided to employees based on their anticipated exposures. The following PPE should be available and used, cleaned, laundered and/or disposed of as appropriate.

  • Disposable gloves, gowns/aprons, shoe covers, surgical masks/caps, and breath saver resuscitators.
  • Eye/face protection devices.
  • Lab coats, clinic jackets.

Gloves, gowns (or aprons, lab coats, or clinic jackets), shoe covers, and masks/caps should be worn when it is reasonably anticipated that an employee may have direct contact with blood or other potentially infectious materials. Disposable breath saver resuscitators provide emergency breathing capability to the victim without direct mouth-to-mouth contact. Eye/face protection devices, such as surgical masks and caps, goggles, glasses with solid side shields, or chin-length face shields, should be worn whenever splashes, spray, spatter, blood droplets, or other potentially infectious materials may be generated.

Vaccinations and Evaluations

All employees who have been identified as having exposure to blood or other potentially infectious materials should be offered the hepatitis B vaccine at no cost to the employee. The vaccine should be offered within 10 working days of their initial assignment, involving the potential for occupational exposure to blood or other potentially infectious materials. Employees who previously had the vaccine may submit to anti-body testing, which shows employees who have sufficient immunity.

Post-exposure evaluations and follow-ups should be provided to an employee who has been exposed to an incident involving the release of blood or potentially infectious materials.

The maintenance record form (included at the end of this plan) includes a record of vaccinations, evaluations, and follow-ups, or an employee’s signed statement declining these services. The completed form should be retained by the personnel department.


All applicable employees should be trained in conjunction with applicable requirements for certification (ex: EMT, CPR, first aid). Where independent training is not available, company-sponsored training should be offered. Annual retraining should also be made available in accordance with OSHA standards. 

Additional training should include:

  • OSHA standards for bloodborne pathogens
  • Exposure control plan review
  • Procedures that may cause exposure to blood or other potentially infectious materials
  • Control methods to be used at the facility
  • Available PPE
  • Hepatitis B vaccination program
  • Post-exposure evaluation and follow-up
  • Signs and labels used at the facility


The maintenance record form maintains information in accordance with OSHA requirements. The completed form should be maintained by the personnel/HR department. The safety director should maintain a summary log of employee training, vaccinations, medical records, sharps injury log, and issued PPE. A sample is provided following the maintenance record form.


Bloodborne Pathogen Exposure Control Maintenance Record

Distribution:   o   Personnel copy   o   Employee copy     o  Supervisor copy      o   Other                       

Employee name:                                                 SS #:                                

Company Name:                                                 Dept:                                 



Hepatitis B Vaccination Record

Date:                                  Physician:                                                                

Date:                                  Physician:                                                                

Date:                                  Physician:                                                                

I have been offered the opportunity to receive a hepatitis B vaccination and hereby decline this opportunity. 



Post-Exposure Evaluation/Follow-up

Date:                                  Incident:                                                                   

Date:                                  Incident:                                                                   

Date:                                  Incident:                                                                   



Policy Receipt and Review Confirmation

I have received a copy of the bloodborne pathogen exposure control plan. I have reviewed the plan, understand it, and agree to abide by it.

Employee signature:                                                                           Date:                     

Supervisor signature:                                                                          Date: