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<CompanyName>

Bloodborne Pathogens Program

Version <Version>

Updated: <Date>

Contents

1.	Program Purpose	1

2.	Responsibilities	1

3.	Definitions	2

4.	Employee Exposure Determination	3

5.	Methods of Implementation & Control	5

6.	Hepatitis B Vaccination	10

7.	Post-exposure Evaluation & Follow-up	11

8.	Post-incident Assessment	12

9.	Employee Training	12

10.	Recordkeeping	13

Appendix I: Hepatitis B Vaccine Declination	15

Appendix II: Universal Precautions	16

Appendix III: Handwashing	17

Appendix IV: Exposure Incident Investigation Form	18

Employee Acknowledgement	19

Program Purpose

<CompanyName> is committed to providing a safe and healthy work environment for our entire staff. In pursuit of this goal, the following Bloodborne Pathogen (BBP) program is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, "Bloodborne Pathogens."

The Exposure Control Plan (ECP) is a key document to assist our organization in implementing and ensuring compliance with the standard, thereby protecting our employees. This ECP includes:

Determination of employee exposure

Implementation of various methods of exposure control, including:

Universal precautions

Engineering and work practice controls

Personal protective equipment

Housekeeping

Hepatitis B vaccination

Post-exposure evaluation and follow-up

Communication of hazards to employees and training

Recordkeeping

Procedures for evaluating circumstances surrounding exposure incidents

Implementation methods for these elements of the standard are discussed in the subsequent pages of this program.

Responsibilities

<JobPosition1> is responsible for the implementation of the overall BBP program and will maintain, review, and update the BBP and ECP at least annually, and whenever necessary to include new or modified tasks and procedures.

Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP.

<JobPosition2> will provide and maintain all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. They will also ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes.

<JobPosition3> will be responsible for ensuring that all medical actions required by the standard are performed and that appropriate employee health and OSHA records are maintained.

<JobPosition4> will be responsible for training, documentation of training, and making the written ECP available to employees and applicable government agencies.

Definitions

Blood – human blood, human blood components, and products made from human blood.

Bloodborne Pathogens – pathogenic microorganisms that are present in human blood and that can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B virus (HBV) and C as well as the human immunodeficiency virus (HIV).

Contaminated – the presence or reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

Contaminated Laundry – laundry that has been soiled with blood or other potentially infectious materials, or may contain sharps.

Contaminated Sharps – any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

Decontaminate – the use of physical or chemical means to remove, inactivate, or destroy the bloodborne pathogens on the surface or item to the point where they are no longer capable of transmitting infectious particles, and the surface or item is rendered safe for handling, use, or disposal.

Disposable – any item indicated as single-use only.

Engineering Controls – controls that isolate or remove the bloodborne pathogen hazards from the workplace.

Exposure – any contact with blood or potentially infectious materials. Direct skin contact with intact skin.

Exposure Incident – a specific mouth, eye, other mucous membrane, non-intact, or parenteral contact with blood or other potentially infectious materials that result from the performance of an employee’s duties.

Handwashing Facility – a facility providing an adequate supply of running potable water, soap, and single-use towels or air drying machine.

Hazard – an actual or potential exposure to risk.

HBV – Hepatitis B virus.

HCV – Hepatitis C virus.

HIV – Human immunodeficiency virus.

Occupational Exposure – reasonably anticipated skin, eye, mucous membrane, or other parenteral contact with blood, or other potentially infectious materials that may result from the performance of an employee’s duties.

Other Potentially Infectious Materials (OPIM) – semen, vaginal fluids, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any fluid contaminated with blood, and all body fluids when it is difficult to distinguish.

Parenteral – piercing mucous membranes, or the skin barrier, through such events as needle sticks, human bites, cuts, and abrasions.

Personal Protective Equipment – specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes not intended to function as protection against a hazard are not considered PPE.

Regulated Waste

Liquid or semi-liquid blood, OPIM

Contaminated items that would release blood or potentially infectious materials in a liquid or semi-liquid state if compressed

Items that are caked with dried blood or OPIM and are capable of releasing these materials during handling

Contaminated sharps

Pathological and microbiological wastes containing blood or OPIM

Sterilize – the use of physical and/or chemical procedures to destroy all microbial life, including highly resistant bacterial endospores.

Universal Precautions – an approach to infection control where all human blood and body fluids are treated as if known to be infectious for HIV, HBV, and/or other bloodborne pathogens.

Work Practice Controls – controls that reduce the likelihood of exposure by altering the manner in which a task is performed.

Employee Exposure Determination

The following is a list of all job classifications at our establishment in which all employees may have occupational exposure. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals:

Job Title	Department/Locations/Tasks
<JobTitle1>	<Dept1>
<JobTitle2>	<Dept2>
<JobTitle3>	<Dept3>
<JobTitle4>	<Dept4>
<JobTitle5>	<Dept5>
<JobTitle6>	<Dept6>
<JobTitle7>	<Dept7>
<JobTitle8>	<Dept8>
<JobTitle9>	<Dept9>
<JobTitle10>	<Dept10>

The following is a list of job classifications in which some employees at our establishment may have occupational exposure. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals:

Job Title	Department/Locations/Tasks
<SomeJobTitle1>	<SomeDept1>
<SomeJobTitle2>	<SomeDept2>
<SomeJobTitle3>	<SomeDept3>
<SomeJobTitle4>	<SomeDept4>
<SomeJobTitle5>	<SomeDept5>
<SomeJobTitle6>	<SomeDept6>
<SomeJobTitle7>	<SomeDept7>
<SomeJobTitle8>	<SomeDept8>
<SomeJobTitle9>	<SomeDept9>
<SomeJobTitle10>	<SomeDept10>

NOTE: Part-time, temporary, contract, and per diem employees are covered by the bloodborne pathogens standard. The ECP should describe how the standard will be met for these employees.

Methods of Implementation & Control

Universal Precautions

All employees will utilize universal precautions

Please refer to Appendix II for additional information

Exposure Control Plan

Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual refresher training. All employees can review this plan at any time during their work shifts by contacting <JobPosition5>, who will provide an employee with a copy of the ECP free of charge and within 15 days of the request.

<JobPosition6> is responsible for reviewing and updating the ECP annually, or more frequently if necessary, to reflect any new or modified tasks and procedures that affect occupational exposure, and to reflect new or revised employee positions with occupational exposure.

Engineering Controls and Work Practices

Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls used are listed below:

List of Engineering Controls in Place
<Control1>
<Control2>
<Control3>
<Control4>
<Control5>
<Control6>
<Control7>
<Control8>
<Control9>
<Control10>

Sharps disposal containers are inspected and maintained or replaced by <JobPosition7> <FrequencyofChange>, or whenever necessary to prevent overfilling.

Hands must always be washed after first-aid treatment contacts (following removal of gloves), after touching inanimate objects likely to be contaminated by blood, and any time there is a potential for contamination. Please refer to Appendix III for additional information.

This facility identifies the need for changes in engineering controls and work practices through:

List of Engineering Control Change Sources
<Change1>
<Change2>
<Change3>
<Change4>
<Change5>
<Change6>
<Change7>
<Change8>
<Change9>
<Change10>

Personal Protective Equipment (PPE)

PPE is provided to our employees at no cost to them. Training in the use of the appropriate PPE for specific tasks or procedures is provided by <JobPosition8>.

The types of PPE available to employees are as follows:

Item	Protection (eyes, hands, face, etc.)
<ListItem1>	<ListProtection1>
<ListItem2>	<ListProtection2>
<ListItem3>	<ListProtection3>
<ListItem4>	<ListProtection4>
<ListItem5>	<ListProtection5>
<ListItem6>	<ListProtection6>
<ListItem7>	<ListProtection7>
<ListItem8>	<ListProtection8>
<ListItem9>	<ListProtection9>
<ListItem10>	<ListProtection10>

PPE is located in <LocationofPPE> and may be obtained through <JobPosition9>, who will ensure that PPE is available.

All employees using PPE must observe the following precautions:

Wash hands immediately, or as soon as feasible, after removing gloves or other PPE.

Remove PPE after it becomes contaminated and before leaving the work area.

Used PPE may be disposed of in the following areas:

List of Disposal Areas
<Area1>
<Area2>
<Area3>
<Area4>
<Area5>
<Area6>
<Area7>
<Area8>
<Area9>
<Area10>

Wear appropriate gloves when it is reasonably anticipated that there may be hand contact with blood or OPIM, and when handling or touching contaminated items or surfaces. Replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised.

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.

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.

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.

Housekeeping

Cleanliness is one of the most important aspects of this program and to the prevention of contraction of bloodborne pathogens from occupational exposures. Employees are trained to promptly dispose of or clean any surface that comes into contact with body fluids, in keeping with other sections of this program.

Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see the following section "Labels"), and closed prior to removal to prevent spillage or protrusion of contents during handling.

Contaminated sharps are discarded immediately, or as soon as possible, in containers that are closable, puncture-resistant, leak proof on sides and bottom, and appropriately labeled or color-coded.

Bins and pails (e.g., wash or emesis basins) are cleaned and decontaminated as soon as feasible after visible contamination.

Broken glassware that may be contaminated is only picked up using mechanical means, such as a brush and dustpan.

After each first-aid case:

Sharps shall be placed in a puncture-resistant container, located throughout the facilities.

Disposable items shall be placed in appropriate waste containers. Disposable items include gauze, towels, cotton products, gloves, masks, and all barriers.

The “spray, wipe, and spray” technique shall be used on all touch and splash surfaces. An EPA registered surface disinfectant shall be applied to the surfaces to be cleaned, wiped off, and then a second coat shall be applied to these same surfaces and allowed to remain in a moist state for the recommended time, per the manufacturer. Although the areas should remain moist, they should not be dripping wet.

Protective coverings, such as plastic trash bags, shall be removed and replaced at the end of the work shift if they have been contaminated during the shift.

All trash containers, pails, and bins shall be routinely cleaned and decontaminated as soon as possible after contamination.

Laundry

The following contaminated articles will be laundered:

Laundry Articles
<Laundry1>
<Laundry2>
<Laundry3>
<Laundry4>
<Laundry5>
<Laundry6>
<Laundry7>
<Laundry8>
<Laundry9>
<Laundry10>

Laundering will be performed by <JobPosition10>.

The following laundering requirements must be met:

Handle contaminated laundry as little as possible, with minimal agitation.

Place wet contaminated laundry in leak-proof, labeled or color-coded containers before transport. <Container> will be used for this purpose.

Labels

The following labeling methods are used in this facility:

Equipment to be Labeled	Label Type (size, color, etc.)
<LabelItem1>	<LabelType1>
<LabelItem2>	<LabelType2>
<LabelItem3>	<LabelType3>
<LabelItem4>	<LabelType4>
<LabelItem5>	<LabelType5>
<LabelItem6>	<LabelType6>
<LabelItem7>	<LabelType7>
<LabelItem8>	<LabelType8>
<LabelItem9>	<LabelType9>
<LabelItem10>	<LabelType10>

<JobPosition11> is responsible for ensuring that warning labels are affixed or red bags are used as required if regulated waste or contaminated equipment is brought into the facility. Employees are to notify <JobPosition11> if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc., without proper labels.

Hepatitis B Vaccination

<JobPosition12> will provide training to employees on hepatitis B vaccinations, addressing safety, benefits, efficacy, methods of administration, and availability.

The hepatitis B vaccination series is available at no cost after initial employee training and within 10 days of initial assignment to all employees identified in the exposure determination section of this plan.

Vaccination is encouraged unless:

Documentation exists that the employee has previously received the series

Antibody testing reveals that the employee is immune

Medical evaluation shows that vaccination is contraindicated

However, if an employee declines the vaccination, the employee must sign a declination form (see Appendix I). Employees who decline may request and obtain the vaccination at a later date at no cost.

Following the medical evaluation, a copy of the healthcare professional's written opinion will be obtained and provided to the employee within 15 days of the completion of the evaluation. It will be limited to whether the employee requires the hepatitis vaccine and whether the vaccine was administered.

Post-exposure Evaluation & Follow-up

An immediately available, confidential medical evaluation and follow-up will be conducted by <FacilityName>. Following initial first-aid (clean the wound, flush the eyes or other mucous membrane, etc.), the following activities will be performed:

Document the routes of exposure and how the exposure occurred.

Identify and document the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law).

Obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV, and HBV infectivity. Document that the source individual's test results were conveyed to the employee's healthcare provider.

If the source individual is already known to be HIV, HCV, and/or HBV positive, new testing need not be performed.

Ensure that the exposed employee is provided with the source individual's test results and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual (e.g., laws protecting confidentiality).

After obtaining consent, collect exposed employee's blood as soon as feasible after exposure incident, and test blood for HBV and HIV serological status.

If the employee does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days. If the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.

Post-incident Assessment

<JobPosition13> will review the circumstances of all exposure incidents to determine:

Engineering controls in use at the time

Work practices followed

A description of the device being used, including type and brand

Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.)

Location of the incident (O.R., E.R., patient room, etc.)

Procedure being performed when the incident occurred

Employee Training

All employees who have occupational exposure to bloodborne pathogens receive initial and annual training.

All employees who have occupational exposure to bloodborne pathogens receive training on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the following elements:

A copy and explanation of the OSHA bloodborne pathogen standard.

An explanation of our ECP and how to obtain a copy.

An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident.

An explanation of the use and limitations of engineering controls, work practices, and PPE.

An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE.

An explanation of the basis for PPE selection.

Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge.

Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM.

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 signs and labels and/or color coding required by the standard and used at this facility.

An opportunity for interactive questions and answers with the person conducting the training session.

Recordkeeping

Training Records

Training records are completed for each employee upon completion of training. These documents will be kept for at least three years. The training records include:

The dates of the training sessions

The contents or a summary of the training sessions

The names and qualifications of persons conducting the training

The names and job titles of all persons attending the training sessions

Medical Records

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, "Access to Employee Exposure and Medical Records."

<JobPosition14> is responsible for maintenance of the required medical records. These confidential records are kept in <LocationofRecords> for at least the duration of employment plus 30 years.

Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to <JobPosition14>.

OSHA Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA's recordkeeping requirements (29 CFR 1904).

Sharps Injury Log

All injuries from contaminated sharps are also recorded in a Sharps Injury Log. All incidences must include at least:

Date of the injury

Type and brand of the device involved (syringe, suture needle)

Department or work area where the incident occurred

Explanation of how the incident occurred

This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

Appendix I: Hepatitis B Vaccine Declination

Hepatitis B Vaccine Declination (Mandatory)

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring the hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the hepatitis B vaccine, at no charge to myself. However, I decline the 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 the hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Employee Name: _________________________________
Employee Signature: ______________________________
Date: __________________________________________

Appendix II: Universal Precautions

Blood and other body fluids shall be considered potentially infectious materials. These precautions are intended to prevent contact exposure to bloodborne pathogens by an employee via parenteral, mucous membrane, and/or non-intact skin. All consumers, clients, and patients will be assumed to be infectious.

It is the company's policy to treat all patients equally by following the standards for Universal Precautions outlined in the Infection Control Protocols.

The term "universal precautions" refers to a system of infectious disease control which assumes that every direct contact with body fluids is infectious and requires every employee exposed to direct contact with body fluids to be protected as though such body fluids were HBV- or HIV-infected. Therefore, universal precautions are intended to prevent healthcare workers from parenteral, mucous membrane, and non-intact skin exposures to bloodborne pathogens.

Universal precautions apply to:

Human blood

Human blood products

Human blood components

Human unfixed tissue and organs (living or dead), other than intact skin

All body fluid visibly contaminated with blood

All body fluids if differentiation is difficult or impossible

Appendix III: Handwashing

Handwashing is the single most effective barrier to microbial transfer.

Components of handwashing:

Water

Agent

Friction

Time

Handwashing Technique:

Begin water flow

Remove jewelry

Moisten hands, other skin surfaces

Apply cleansing agent

Apply friction (rub):

Finger planes

Web spaces

Fingernails

Time – dependent upon exposure

Rinse thoroughly under running water

Dry thoroughly with disposable towels

Utilize drying towel to turn faucet to “off” position

Discard drying towel in designated container

Appendix IV: Exposure Incident Investigation Form

Date of Incident: __________________________________________________________

Time of Incident: __________________________________________________________

Location: ________________________________________________________________

Potentially Infectious Materials Involved:

Type: _____________________________________________________________

Source: ___________________________________________________________

Circumstances (work being performed, etc.): ___________________________________

How Incident Was Caused (accident, equipment malfunction, etc.):

_________________________________________________________________________

Personal Protective Equipment Being Used: _____________________________________

Actions Taken (decontamination, clean-up, reporting, etc.):

_________________________________________________________________________

Recommendations for Avoiding Repetition:

_________________________________________________________________________

Report Prepared by:	_______________________________ Date: _________________

Supervisor: _______________________________________ Date: ________________

Employee Acknowledgement

I have received information on <CompanyName>’s Bloodborne Pathogens Program. By signing below, I agree to abide by the procedures in this document and bring to the attention of my supervisor any questions or concerns had.
Employee Name: _________________________________
Employee Signature: ______________________________
Date: ___________________________________________