06-11.01 鈥� Occupational Exposure to Bloodborne Pathogens

  1. Policy Statement:

    It is recognized that certain job activities at 色花堂 (鈥淯niversity鈥�) may result in occupational exposure to human blood and other body fluids. It is also recognized that some of these body fluids may contain bloodborne pathogens such as the hepatitis B virus (HBV) and the human immunodeficiency virus (HIV). This is a statement of official University policy to describe the mechanism for compliance with the Occupational Safety and Health Administration (OSHA) regulation, 鈥淥ccupational Exposure to Bloodborne Pathogens; Final Rule鈥� (29 CFR Part 1910.1030) to insure worker safety and environmental protection. 

  2. Reason for Policy:

    The University is dedicated to providing a safe workplace for employees, and to complying with federal and state occupational health and safety standards. Laboratory administrators, managers, supervisors, faculty and staff share responsibility for minimizing their occupational exposure to human blood and other potentially-infectious materials. 

  3. Definitions: 

    1. 鈥淗uman Blood鈥� is defined as human blood, human blood components, and products made from human blood. 

    2. 鈥淥ther Potentially Infectious Materials鈥� is defined as (1) semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and body fluids that are visibly contaminated with blood, all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) any unfixed tissue or organ (other than intact human skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. 

    3. 鈥淏iological, Pathological and Medical Waste鈥� is defined as anatomical material, blood or blood soiled articles, contaminated material (feces or articles contaminated with infectious agents), microbiological laboratory waste, needles, sharps, and syringes. 

    4. 鈥淓xposure Control Plan鈥� is defined as a written plan designed to eliminate or minimize employee occupational exposure to blood and other potentially infectious materials. 

    5. 鈥淥ccupational Exposure鈥� is defined as skin, mucous membrane or parenteral contact with Human Blood or other Potentially Infectious Material. 

  4. Responsible Executive and Office:

    Responsible Executive:
    Vice President for Administration and Finance and Chief Fiscal Officer

    Responsible Office:
    Environmental Health and Safety

  5. Entities Affected by this Policy:

    Laboratory administrators, managers, supervisors, faculty and staff. 

  6. Procedures: 

    1. The Exposure Control Plan shall be implemented for all departments at the University where performance of employees鈥� duties can be expected to result in Occupational Exposure.

      The Exposure Control Plan shall be reviewed and evaluated for its effectiveness at least annually. It will be updated as needed to reflect new or modified procedures which affect Occupational Exposure and to reflect new or revised employee positions with Occupational Exposure.

    2. Responsibilities 

      1. The Department of Environmental Health and Safety shall:

        1. prepare the Exposure Control Plan with annual review, and revisions as necessary; 

        2. distribute the plan to each affected worksite; 

        3. investigate, document and maintain the records of an incident of suspected exposure to Human Blood or other Potentially Infectious Material for all University employees except those of the 色花堂 Health Center; 

        4. Maintain records of employee vaccination records or the declination statements for hepatitis B immunizations for all University employees except those of the Towson University Health Center; 

        5. collect and dispose of Biological, Pathological and Medical Waste; 

        6. provide or coordinate training for all affected workers (as specified in the 鈥淭raining鈥� section below) concerning the following: 

          1. applicable regulations and provisions of the Exposure Control Plan; 

          2. epidemiology and symptoms of bloodborne diseases; 

          3. measures to protect employees from contact with other Potentially Infectious Materials;

          4. information about and availability of effective vaccines; and

          5. procedures to follow if exposure to other Potentially Infectious Materials occurs or is suspected; 

        7. prepare an exposure determination which shall contain the following:

            1. a list of all job classifications in which all employees in those job classifications have Occupational Exposure;

            2. a list of job classifications in which some employees have Occupational Exposure; and 

            3. a list of all tasks and procedures or groups of closely related tasks and procedures in which Occupational Exposure occurs and that are performed by employees in job classifications listed in accordance with the provision of the OSHA standard.

          This exposure determination shall be made without regard to the use of personal protective equipment. 

      2. The 色花堂 Health Center shall provide the following for employees of the 色花堂 Health Center:

        1. provide or direct all required or recommended medical examinations, treatment and counseling following an exposure incident; 

        2. provide vaccinations, as required; 

        3. maintain medical records relating to consultations, examinations and medical surveillance as required by law; and 

        4. assist with training to University employees, as required. 

      3. Departments shall ensure:

        1. exposed employees are sent to local area hospitals for recommended medical examinations, treatment and counseling following an exposure incident 

        2. follow-up examinations are performed by local area hospitals; and 

        3. ensure all medical records are sent to the Department of Environmental Health and Safety;

      4. The University Police Department (鈥溕ㄌ肞D鈥�) shall ensure departmental attendance to BBP training provided by the Department of Environmental Health and Safety, as required. 

      5. The Nursing Department and Sports Medicine (Athletic Trainers) shall provide training to departmental employees, as required.

      6. The affected department heads shall: 

        1. ensure the provision of all necessary training, equipment and medical services required by the Exposure Control Plan; 

        2. ensure that the Exposure Control Plan is accessible to all employees in the worksite and that the employees comply with the requirements of the plan; 

        3. provide specific work practice training; and 

        4. maintain copies of training records in departmental personnel files. 

      7. University employees with Occupational Exposure to Human Blood or other Potentially Infectious Materials shall: 

        1. adhere to the requirements of the Exposure Control Plan; 

        2. complete all safety training requirements and comply with documentation procedures; 

        3. report all suspected exposure incidents; and 

        4. follow procedure for injured workers with the Human Resources Benefits Manager. 

    3. Information

      Assistance will be provided by the Department of Environmental Health and Safety and the 色花堂 Health Center to any department requesting guidance or training to satisfy implementation of this policy. A complete copy of the Exposure Control Plan can be obtained from the Department of Environmental Health and Safety.

Related Policies:

None.

Approval Date: 07/01/2008

Effective Date: 07/01/2008

Amended Date: 05/18/2009

Approved By: President鈥檚 Council 6/20/2008

Signed By: President鈥檚 Council

How to Request the Policy PDF

This online version of the policy may include updated links and names of departments. To request a PDF of the original, signed version of this policy, email the Office of the General Counsel, .