The following exposure control plan has been developed in accordance with the OSHA Standard on Bloodborne Pathogens, 29 CFR 1910.1030. It can be modified for your particular workplace by filling in the spaces and adding to it. The sections within this document that are italicized are informational.
The exposure control plan must be made accessible to employees. In addition, the OSHA standard requires that the components of this written document be implemented.
Federal Occupational Health and Safety Administration (OSHA) does not cover public sector workplaces in Massachusetts. However, Massachusetts General Law Chapter 149 section 6 states that the Department of Labor Standards shall investigate places of employment and determine what suitable devices or other reasonable means or requirements are necessary for the prevention of industrial or occupational diseases.
In the absence of specific standards, it is the policy of our office that public sector workplaces follow the OSHA Standards as a minimum. Compliance with the OSHA Standards will in most cases ensure compliance with the intent of Chapter 149 section 6.
Note: the exposure control plan should be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. The employer shall solicit input from workers as to effective work practice and engineering controls and shall document this in the exposure control plan.
1. Exposure Determination:
An employer must make an exposure determination about which employees may incur occupational exposure to blood or other potentially infectious materials (OPIM). OPIM include the following body substances: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. Potential exposure to human bites also constitutes an exposure. Employees are considered to be "exposed" regardless of the frequency of exposure and even if they use personal protective equipment.
Within this workplace, everyone in the following job classifications are considered to be exposed to blood or OPIM (e.g., all nurses, custodians)
If there are some job classifications in the workplace in which some, but not all, employees may have occupational exposure, then the following should be listed.
Within this workplace, employees in the following jobs are considered to be exposed if they do the following tasks (e.g., workers in addition to custodians who clean up blood, vomitus, or who are designated to provide CPR):
Job Classification Tasks/Procedures
2A. Compliance Methods: Universal Precautions
Regardless of the perceived or known health status of the staff or others (e.g., clients) that employees are dealing with, universal precautions will be observed. All blood or OPIM will be considered potentially infectious and steps will be taken to avoid direct contact with blood or OPIM. Alternatively, body substance isolation may be used; this is when all body fluids or substances are considered to be potentially infectious regardless of whether there is visible blood mixed in or not.
Universal precautions (or body substance isolation) is utilized by this workplace. Indicate which: ______________________________________
All individuals will be considered potentially infectious regardless of how much is known about the person's health status.
2B. Compliance Methods: Engineering and Work Practice Controls
Engineering controls (controls that isolate or remove the hazard from the workplace) and work practice controls will be utilized, as appropriate, to eliminate or minimize exposure to employees of the school. Where occupational exposure remains after institution of these controls, personal protective equipment shall be used.
The following engineering controls will be utilized as appropriate (all may not apply to your agency; indicate which do apply):
- Contaminated sharps (e.g., broken glassware or other sharp object) will not be picked up by hand. For example, a dustpan and broom will be used instead or tongs (with gloves) will be used for needles. List the method used by the workplace: ________________________________________________________
- If needles are used, safer needle systems (e.g., retractable needles) will be used. Define the type(s) used by the workplace: ______________________________ ________________________________________________________________
- Sharps containers will be readily available if there is the potential for dealing with needles and/or other sharps. Define the various types used: _______________________________________________________________
- If applicable, other engineering controls that are used by this workplace are: ___________________________________________________________________________
The following work practices will be followed. (Indicate which apply):
- Washing with soap and water immediately after skin contact with blood or OPIM or immediately after removal of gloves. Washing facilities are located at _________________________________________________________.
- If soap and water are not immediately available, then waterless, antiseptic hand cleanser will be made readily available. Indicate the type of hand cleanser available:_____________________________________. Soap and running water will be used as soon as feasible.
- Mucous membranes will be flushed with water immediately or as soon as feasible after contact with blood or OPIM. Flushing facilities are located at (e.g., nurse's or safety office, local hospital). Indicate where _____________________________________________.
- No eating, drinking or smoking is allowed in areas where blood or OPIM could be present.
- Gloves will be inspected for holes/tears when put on. They will be replaced if holes or tears are present.
- Gloves will be replaced as soon as possible if they become ripped or soiled. Employees should wash their hands as soon as possible after removing gloves.
- Any non-disposable equipment or surface that becomes contaminated with blood or OPIM shall be decontaminated with an approved disinfecting agent and air dried unless the employer determines that this is not feasible. Indicate the type of disinfectant used: ________________________________________________________________
- Contaminated items, other than sharps (such as blood soaked bandages) should be placed in the regulated waste container. Indicate where the container(s) are located : _________________________________________________________________
- Contaminated needles and other contaminated sharps will not be bent, recapped removed, sheared or purposely broken.
- Contaminated sharps shall be placed in the puncture resistant, leak proof, labelled waste container located ______________________________________________ ________________________________________________________________.
- Contaminated equipment will not be cleaned in living/eating areas. Indicate where the equipment is cleaned: ____________________________________
- Other work practices that are appropriate for our workplace include: _________________________________________________________________
2C. Compliance Methods: Personal protective equipment
All personal protective equipment (PPE) will be provided at no cost to employees of the workplace. PPE will be chosen based on the anticipated exposure to blood or OPIM. The PPE will be considered appropriate only if it does not permit blood or OPIM to pass through or reach the employees' clothing, skin, eyes, mouth, or other mucous membranes for the duration of time that the PPE will be used.
The responsible person for seeing that the PPE is provided and replaced as needed at no cost to the employee is (indicate who is responsible): ______________________________________________________________
The equipment consists of:
- Gloves for exposure to blood and OPIM: available in different sizes and different materials (e.g., nitrile or vinyl) if individuals are sensitive to latex
- Gloves (utility or heavy duty) for when disinfecting surfaces
- Chin length face shields or goggles and a surgical mask to protect the mucous membranes
- CPR shields; list others: ______________________________________________________________
- Disposable, fluid resistant clothing (e.g., one-piece disposable coveralls; disposable gown).
The decision to use one of these items vs. other protective gear that is available will be dependent on the nature of the task. The decision is left to the individual worker but the various types of PPE are available.
- Other as follows: _______________________________________________________________
- PPE is kept (indicate where: e.g., main office, nurse's office, custodian's area): ______________________________________________________________
Contaminated PPE should be placed in the regulated waste container or regulated waste bag located in ___________________________________________________________
Disposable gloves are 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. Indicate method for cleaning: _______________________________________________________________________
2D. Compliance Methods: Disinfection
Decontamination of surfaces and equipment will be done as soon as possible after contact with blood or OPIM. Decontamination will be done by utilizing the following substance(s): ________________________________________________________________________
Note: A solution of one part bleach to ten parts water is effective as long as it is made on a daily or an as needed basis; it begins to lose its effectiveness within 24 hours after being made up. A commercial disinfectant must be an EPA approved tuberculocidal and should be used in accordance with the manufacturer's directions.
If there is equipment that would potentially need to be disinfected, the designated area for disinfection in this workplace is: (indicate, for example, where disinfection of equipment is done). Also, indicate whose responsibility it is to disinfect
2E. Compliance Methods: Regulated Waste
Regulated waste will be disposed of in accordance with the MA Department of Public Health Regulation 105 CMR480.000 (Storage and Disposal of Infectious or Physically Dangerous Medical or Biological Waste) in addition to the OSHA standard on bloodborne pathogens. Regulated waste would include liquid or semi-liquid blood or OPIM; materials that are saturated or dripping with blood or OPIM; items that are caked with dried blood or OPIM; contaminated sharps.
- Regulated waste, other than sharps, shall be placed in the regulated waste containers or regulated waste bag located _______________________________________________________________.
- Contaminated sharps will be discarded in the sharps container located_________________________________________________________
- It is the responsibility of (indicate who) ______________________________ to see that regulated waste containers are not overfilled and that they are properly disposed of. The waste container is emptied when ________________________________________________________________
(indicate, for example, when the container is half full or when it is filled up to a certain line).
- Regulated waste will be disposed of in the following manner: _________________________________________________________
________________________________________________(indicate the name of the licensed waste hauler or indicate the name of a local hospital or other organization with which your workplace has an agreement/contract to dispose of the waste).
2F. Compliance Methods: Laundry
If there is potential for laundry to be contaminated with blood or other potentially infectious materials (OPIM), then it will be handled as little as possible. Such laundry will be placed in appropriately marked bags. Employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or OPIM.
- Laundry that becomes contaminated is the responsibility of the workplace. The laundry will be cleaned at __________________________ (indicate whether washer/dryer is available or whether there is a contract with a laundry service). If the laundry is being sent off site, then the laundry service accepting the laundry is to be notified.
- Hepatitis B Vaccine
All employees who have been identified as having exposure to blood or OPIM will be offered the Hepatitis B vaccine, at no cost to the employee. The vaccine will be offered within ten working days of their initial assignment to work involving the potential for occupational exposure to blood or OPIM unless the employee previously had the vaccine or wishes to submit to antibody testing which shows the employee to have sufficient immunity.
Employees who decline the vaccine will sign a waiver which uses the wording in Appendix A of the OSHA Standard (see attached appendix A on page 14).
Employees who initially decline the vaccine but who later wish to have it may then have the vaccine provided at no cost.
Doing a titre or providing a booster will be done in accordance with recommendations of the Centers for Disease Control and Prevention (CDC).
Note: CDC currently recommends that a titre be offered one to two months after the third shot for those workers (e.g., health care workers and public safety workers) who have ongoing exposure to needlestick injuries and mucosal exposure to blood or other potentially infectious materials. Persons who do not respond to the primary vaccine series should complete a second three-dose vaccine series or be evaluated to determine if they are HbsAg-positive. Revaccinated persons should be retested at the completion of the second vaccine series. Persons who prove to be HbsAg positive should be counselled accordingly. Primary non-responders to vaccination who are HbsAg-negative should be counselled regarding precautions to prevent Hepatitis B infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to HbsAg- positive blood.
Indicate who has the responsibility to ensure that the above will be followed: ______________________________________________________________
- Post-exposure evaluation and follow-up
The follow-up will be in accordance with OSHA and the MA Department of Public Health regulations.
When an employee incurs an unprotected exposure to blood or OPIM, it should be reported to ___________________________________________________.
Any forms specific to this workplace will be filled out. These include the following: ________________________________________________________________
Any follow-up or evaluation of the exposed employee(s) will be done by (indicate where the employee may receive care (e.g., hospital or clinic or his/her own physician). ______________________________________________________________________
Option should be given to employee of dealing with his/her own physician. However, a copy of the OSHA standard should be provided to the physician and the physician must be familiar with CDC guidelines for post-exposure.
The follow-up will include the following:
- Documentation of the route of exposure and the circumstances related to the incident
- If possible, the identification of the source individual will be obtained. If consent from the source individual is obtained, his/her blood may be tested for infectivity and results of any testing will be made available to the exposed worker. (A rapid HIV test is currently available and should be considered for use).
- Note: The employer does not obtain the source individual's blood test results. It is the employer's responsibility to ensure that steps are in place to try to obtain consent and to make arrangements for the blood results to be available to the exposed employee.
- The following means will be used to contact the source individual and try to obtain consent for HIV, HBV, or HCV testing as soon as feasible: ___________________________________________________________________
- If consent is not obtained from the source of the exposure, it shall be documented that consent cannot be obtained.
- The employee will be offered the option of having his or her blood collected for testing of his or her HIV/Hepatitis serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested.
- The employee will be given appropriate counselling 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.
- The medical evaluation and follow-up will be in accordance with the current recommendations of the U.S. Public Health Service.
- The following person has been designated to assure that the policy outlined here is effectively carried out as well as to maintain records related to this policy: ______________________________________________________.
- Other policies and procedures for the workplace include: ____________________________________________________________
- Employer Interaction with the Healthcare Professional
The workplace (indicate who has responsibility ) ________________________________________________________________________ shall obtain a written opinion from the healthcare professional who evaluates the employee and the healthcare professional who administers the Hepatitis B vaccine series. The opinion shall be limited to:
- Whether the Hepatitis B vaccine series is indicated and if the employee has received it.
- Indication that the employee has been informed of the results of the medical evaluation.
- Indication that the employee has been told about any medical conditions resulting from exposure.
Note: The written opinion to the employer or his/her designee does not reference any personal medical information.
_________________________ (indicate who) will be responsible for maintaining all medical records.
_____________________ (indicate who) shall ensure that these records are kept confidential and that they are not disclosed or reported without the employee's expressed written consent. These records shall be for the duration of employment plus 30 years.
Training for all employees who are reasonably anticipated to have occupational exposure to blood and OPIM will be conducted prior to the initial assignment and annually. Training will be conducted by a qualified person (indicate the responsible person) ______________________________.
Training records will be maintained by (indicate the responsible person) _________________________________________
__________________________ For three years from the date on which the training occurred.
Training will include:
- The OSHA Bloodborne Pathogens Standard
- Epidemiology and symptoms of bloodborne diseases
- Modes of transmission of bloodborne diseases
- This exposure control plan, i.e., points of the plan, lines of responsibility, how the plan will be implemented, etc
- An explanation of appropriate means of recognizing activities and procedures that may result in exposure to blood or other potentially infectious materials
- Control measures
- Personal protective equipment available in this workplace and an explanation of the basis for its selection and use
- Post-exposure follow/up and evaluation
- The reporting procedures that an employee of the workplace should follow
- Signs and labels used in this department for biohazardous materials
- Hepatitis B vaccine program
A sharps injury log will be established and maintained by the employer for the recording of percutaneous injuries from contaminated sharps (those that break the skin). The log shall contain:
- The type of device involved;
- Where the incident occurred;
- How the incident occurred.
All records will be maintained by
Appendix A to Section 1910.1030:
Hepatitis B Vaccine Declination
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.
Hazard Information Bulletin 412, Exposure Control Plan Municipal
Publish Date: 03/2009
Massachusetts Department of Labor Standards
Workplace Safety and Health Program
1001 Watertown Street, West Newton, MA 02465