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Bloodborne Pathogen Requirements

Section G: Personnel

Regulation Title: Bloodborne Pathogen Requirements
Regulation Code: GBGC-R3

Print Version (in PDF)

Exposure Control Plan

Employee(s) with occupational exposure to human blood, human blood components, products made from human blood, or pathogenic microorganisms, including but not limited to Hepatitis B virus or HIV, shall comply with this Exposure Control Plan designed to eliminate or minimize employee exposure.

This Exposure Control Plan contains the following elements:

  • The exposure determination outlined below.
  • The schedule and method of implementation.
  • The procedure for the evaluation of circumstance surrounding exposure.

A copy of this Exposure Control Plan shall be accessible to employees.

This Exposure Control Plan shall be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures that affect occupational exposure, and to reflect new or revised employee positions with occupational exposure.

This Exposure Control Plan shall be made available to the Assistant Secretary of Labor and the Director of the Occupational Safety and Health Administration upon request for examination and copying.

Exposure Determination

The District has determined that employee positions may involve the following levels of exposure to bloodborne pathogens as a collateral function to the primary job description:

  • High risk - Coaches, physical education instructors, custodians, certain special education program personnel, playground duty personnel, health services personnel, and security personnel.
  • Moderate risk - Regular instructional program personnel, other special education program personnel, school level office personnel, maintenance personnel, food services personnel, and special assignment personnel (e.g., counselors, librarians).
  • Low risk - District level office personnel.

Methods of Compliance

General. Universal precautions shall be observed by all District employees to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials.

Engineering and work practice controls:

  • Engineering and work practice controls shall be used to eliminate or minimize employee exposure. If occupational exposure remains after institution of these controls, personal protective equipment shall also be used.
  • Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness.
  • The District shall provide hand-washing facilities that are readily accessible to employees.
  • When provision of hand-washing facilities is not feasible, the District shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as feasible.
  • The District requires that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment. Supervisory personnel shall ensure compliance.
  • The District requires that employees wash hands and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials. Supervisory personnel shall ensure compliance.
  • Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except as noted below. Shearing or breaking of contaminated needles is prohibited.
    • Contaminated needles and other contaminated sharps shall not be recapped or removed unless no other alternative is feasible or such action is required by a specific medical procedure as determined by a competent medical professional qualified to make such determination.
    • Such recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique.
  • Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed.
  • Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
  • Food and drink shall not be kept in refrigerators, freezers, shelves, or cabinets, or on countertops or bench tops where blood or other potentially infectious materials are present.
  • All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.
  • Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
  • Specimens of blood or other potentially infectious materials shall be placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping.
    • The container for storage, transport, or shipping shall be labeled or color coded according to law and closed prior to being stored, transported, or shipped. When a facility utilizes "universal precautions" in the handling of all specimens, the labeling/color coding of specimens is not necessary, provided containers are recognizable as containing specimens. This exemption applies only while such specimens/containers remain with the facility. Labeling or color coding is required when such specimens/ containers leave the facility.
    • If outside contamination of the primary container occurs, the primary container shall be placed within a second container that prevents leakage during handling, processing, storage, transport, or shipping and is labeled or color coded according to the requirements of this standard.
    • If the specimen could puncture the primary container, the primary container shall be placed within a secondary container that is puncture resistant in addition to the above characteristics.
  • Equipment that may become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary, unless the decontamination of such equipment or portions of such equipment is not feasible as determined by a supervisory employee assigned to make such determination.
    • A readily observable label in accordance with law shall be attached to the equipment stating which portions remain contaminated.
    • This information shall be conveyed to all affected employees, the servicing representative, and/or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions will be taken.

Personal protective equipment:

  • Provision. When occupational exposure occurs, the District shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered "appropriate" only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time that the protective equipment will be used.
  • Use. The District requires that all exposed employees use appropriate personal protective equipment unless the District documents that a specific employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was such employee's professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the circumstances shall be reported by the employee and investigated and documented by the District in order to determine whether changes can be instituted to prevent such occurrences in the future.
  • Accessibility. Appropriate personal protective equipment in the appropriate sizes must be readily accessible at the work site or issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to employees who are allergic to the gloves normally provided.
  • Cleaning, laundering, and disposal. The District shall clean, launder, and dispose of personal protective equipment required in this standard, at no cost to the employee.
  • Repair and replacement. The District shall repair or replace personal protective equipment as needed to maintain its effectiveness, at no cost to the employee.
  • Any garment(s) penetrated by blood or other potentially infectious materials shall be removed immediately or as soon as feasible.
  • All personal protective equipment shall be removed prior to leaving the work area.
  • When personal protective equipment is removed it shall be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.
  • Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and nonintact skin; when performing vascular access procedures; and when handling or touching contaminated items or surfaces.
    • Disposable (single-use) gloves, such as surgical or examination gloves shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or their ability to function as a barrier is compromised.
    • Disposable (single-use) gloves shall not be washed or decontaminated for reuse.
    • Utility gloves may be decontaminated for reuse if the integrity of the gloves is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

Housekeeping:

  • General. The work site must be maintained in a clean and sanitary condition. The District shall establish, attach hereto, and implement an appropriate written schedule for cleaning and the method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area.
  • All school activity areas are cleaned daily.
  • All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.
    • Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures, immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials, and at the end of the work shift if the surface may have become contaminated since the last cleaning.
    • Protective coverings - such as plastic wrap, aluminum foil, or imperviously backed absorbent paper used to cover equipment and environmental surfaces - shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.
    • All bins, pails, cans, and similar receptacles intended for reuse that have a reasonable likelihood of becoming contaminated with blood or other potentially infectious materials shall be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.
    • Broken glassware that may be contaminated shall not be picked up directly with the hands. It shall be cleaned up using mechanical means such as a brush and dust pan, tongs, or forceps.
    • Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.
  • Regulated waste:
    • Contaminated sharps discarding and containment:
      • Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are:
        • Closable
        • Puncture resistant
        • Leak proof on sides and bottom
        • Labeled or color coded
      • During use, containers for contaminated sharps shall be:
        • Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., laundries).
        • Maintained upright throughout use.
        • Replaced routinely and not be allowed to overfill.
      • When moving containers of contaminated sharps from the area of use, the containers shall be:
        • Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
        • Placed in a secondary container if leakage is possible. The second container shall be:
          • Closable
          • Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping
          • Labeled or color coded
      • Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner that would expose employees to the risk of percutaneous injury.
    • Other regulated waste containment:
      • Regulated waste shall be placed in containers that are:
        • Closable
        • Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping.
        • Labeled or color coded
        • Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping
      • If outside contamination of the regulated waste container occurs, it shall be placed in a second container. The second container shall be:
        • Closable
        • Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping.
        • Labeled or color coded
        • Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping
    • Disposal of all regulated waste shall be in accordance with applicable regulations of the United States, states, territories, and political subdivisions of states and territories.
  • Laundry:
    • Contaminated laundry shall be handled as little as possible, with a minimum of agitation.
      • Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use.
      • Contaminated laundry shall be placed and transported in bags or containers labeled or color coded. When a facility utilizes universal precautions in the handling of all soiled laundry, alternative labeling or color coding is sufficient if it permits all employees to recognize the containers as requiring compliance with universal precautions.
      • Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through of or leakage from the bag or container, the laundry shall be placed and transported in bags or containers that prevent soaking-through and/or leakage of fluids to the exterior.
    • Employees who have contact with contaminated laundry must wear protective gloves and other appropriate personal protective equipment.
    • When a facility ships contaminated laundry off-site to a second facility, which does not utilize universal precautions in the handling of all laundry, the facility generating the contaminated laundry must place such laundry in bags or containers that are labeled or color-coded.

Hepatitis B Vaccination and Post Exposure

Evaluation and Follow-up

General:

  • The District shall make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post exposure evaluation and follow-up to all employees who have had an exposure incident.
  • The District requires that all medical evaluations and procedures, including the hepatitis B vaccine, and vaccination series and post exposure evaluation and follow-up, including prophylaxis, are:
    • Made available at no cost to the employee.
    • Made available to the employee at a reasonable time and place.
    • Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed health care professional.
    • Provided according to recommendations of the U.S. Public Health Service current at the time these evaluations and procedures take place, except as specified in this section on hepatitis B vaccination and post exposure evaluation and follow-up.
  • The District requires that all laboratory tests be conducted by an accredited laboratory at no cost to the employee.

Hepatitis B vaccination:

  • Hepatitis B vaccination shall be made available after the employee has received the training required and within ten (10) working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.
  • The District shall not make participation in a prescreening program a prerequisite for receiving hepatitis B vaccination.
  • If the employee initially declines hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the District shall make available hepatitis B vaccination at that time.
  • The District requires all employees who decline to accept hepatitis B vaccination that is offered to sign the following statement:

    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.

  • If a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster dose(s) shall be made available.

Post exposure evaluation and follow-up. Following a report of an exposure incident, the District shall make immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the following elements:

  • Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred.
  • Identification and documentation of the source individual, unless the District can establish that identification is infeasible or prohibited by state or local law.
    • The source individual's blood shall be tested as soon as feasible, and after consent is obtained, in order to determine HBV and HIV infectivity. If consent is not obtained, the District shall establish that legally required consent cannot be obtained. When the source individual's consent is not required by law, the source individual's blood, if available, shall be tested and the result documented.
    • When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated.
    • Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.
  • Collection and testing of blood for HBV and HIV serological status:
    • The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained.
    • If the employee consents to base-line blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least ninety (90) days. If within ninety (90) days of the exposure incident the employee elects to have the base-line sample tested, such testing shall be done as soon as feasible.
  • Post exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service.
  • Counseling.
  • Evaluation of reported illnesses.

Information provided to the health care professional:

  • The health care professional responsible for the employee's hepatitis B vaccination shall be provided a copy of this document.
  • The health care professional evaluating an employee after an exposure incident shall be provided the following information:
    • A copy of this document.
    • A description of the exposed employee's duties as they relate to the exposure incident.
    • Documentation of the route(s) of exposure and circumstances under which exposure occurred.
    • Results of the source individual's blood testing, if available.
    • All medical records relevant to the appropriate treatment of the employee, including vaccination status that are the District's responsibility to maintain.

Health care professional's written opinion. The District shall obtain and provide the employee with a copy of the evaluating health care professional's written opinion within fifteen (15) days of the completion of the evaluation.

  • The health care professional's written opinion for hepatitis B vaccination shall be limited to whether hepatitis B vaccination is indicated for an employee and whether the employee has received such vaccination.
  • The health care professional's written opinion for post exposure evaluation and follow-up shall be limited to the following information:
    • That the employee has been informed of the results of the evaluation.
    • That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials that require further evaluation or treatment.
  • All other findings or diagnoses shall remain confidential and shall not be included in the written report.

Medical record keeping. Medical records required by this standard shall be maintained.

Communication of Hazards to Employees

Labels:

  • Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material, and other containers used to store, transport, or ship blood or other potentially infectious materials, except as provided in law.
  • These labels shall contain the "biohazard" label.
  • These labels shall be fluorescent orange or orange-red or predominantly so, with lettering or symbols in a contrasting color.
  • Labels are required to be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.
  • Red bags or red containers may be substituted for labels.
  • Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirements of this section on communication of hazards to employees.
  • Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment, or disposal are exempted from the labeling requirements.
  • Labels required for contaminated equipment shall be in accordance with this section and shall also state which portions of the equipment remain contaminated.
  • Regulated waste that has been decontaminated need not be labeled or color coded.

Information and training:

  • All employees with occupational exposure shall participate in a training program, which must be provided at no cost to the employees and during working hours.
  • Training shall be provided as follows:
    • At the time of initial assignment to tasks where occupational exposure may take place.
    • Within ninety (90) days after the effective date of the standard.
    • At least annually thereafter.
  • For employees who have received training on bloodborne pathogens in the year preceding the effective date of the standard, only training with respect to the provisions of the standard that were not included need be provided.
  • Annual training for all employees shall be provided within one (1) year of their previous training.
  • The District shall provide additional training when changes such as modification of tasks or procedures or institution of new tasks or procedures affects the employee's occupational exposure. The additional training may be limited to addressing the new exposures created.
  • Material appropriate in content and vocabulary to educational level, literacy, and language of employees shall be used.
  • The training program shall contain at a minimum the following elements:
    • An accessible copy of the regulatory text of this standard and an explanation of its contents.
    • A general explanation of the epidemiology and symptoms of bloodborne diseases.
    • An explanation of the modes of transmission of bloodborne pathogens.
    • An explanation of the District's Exposure Control Plan and the means by which the employee can obtain a copy of the written plan.
    • An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
    • An explanation of the use and limitations of methods that will prevent or reduce exposure, including appropriate engineering controls, work practices, and personal protective equipment.
    • Information on the types, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment.
    • An explanation of the basis for selection of personal protective equipment.
    • Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge.
    • Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
    • 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 District is required to provide for the employee following an exposure incident.
    • An explanation of the labels and/or color coding required.
    • An opportunity for interactive questions and answers with the person conducting the training session.
  • The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace that the training will address.

Record Keeping

Medical records:

  • The District shall establish and maintain an accurate record for each employee with occupational exposure as defined herein.
  • This record shall include:
    • The name and Social Security number of the employee.
    • A copy of the employee's hepatitis B vaccination status, including the dates of all hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination.
    • A copy of all results of examinations, medical testing, and follow-up procedures.
    • The District's copy of the health care professional's written opinion.
    • A copy of the information provided to the health care professional.
  • Confidentiality. The District shall ensure that employee medical records required by law are:
    • Kept confidential
    • Not disclosed or reported, without the employee's express written consent, to any person within or outside the workplace, except as required by law.
  • The District shall maintain the records required by law for at least the duration of employment plus thirty (30) years.

Training records:

  • Training records shall include the following information:
    • 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.
  • Training records shall be maintained for three (3) years from the date on which the training occurred.

Availability:

  • The District shall ensure that all records required to be maintained shall be made available, upon request, to the Assistant Secretary of Labor and the Director of the Occupational Safety and Health Administration for examination and copying.
  • Employee training records required by law shall be provided upon request for examination and copying to employees, to employee representatives, to the Director of the Occupational Safety and Health Administration, and to the Assistant Secretary of Labor.
  • Employee medical records required by law shall be provided upon request, for examination and copying, to the subject employee, to anyone having written consent of the subject employee, to the Director of the Occupational Safety and Health Administration, and to the Assistant Secretary of Labor.

Transfer of records:

  • The District shall comply with the legal requirements involving transfer of records.
  • If the District ceases to do business and there is no successor district to receive and retain the records for the prescribed period, the District shall notify the Director of the Occupational Safety and Health Administration, at least three (3) months prior to their disposal, and transmit them to the Director of the Occupational Safety and Health Administration, if required by the Director of the Occupational Safety and Health Administration to do so, within that three (3) month period.

Adopted: November 9, 2012 [Friday Report]
Revised: February 28, 2014 [Friday Report]