11.5 – Bloodborne Pathogens Exposure Control Plan

POLICY:  Spoon River College will take universal precautions at College facilities in order to prevent contact with blood or other potentially infections materials.  All blood or other potentially infectious materials are considered infectious regardless of the perceived status of the source individual.

Employees are categorized pursuant to Illinois Department of Labor Rules and Regulations.  All employees in Category 1 (as defined below) are offered Hepatitis B vaccine series at College expense.  All other employees, at college expense, are offered vaccinations when exposure to infectious material has been suspected.  All such actions are to be documented via approved forms.  This plan will set forth procedures to be utilized in all such situations.  The plan must be reviewed and updated at least annually or whenever new tasks and procedures are introduced to the work environment.

All suspected or confirmed exposures to infectious material(s) are considered confidential and will be treated as such.


Administrative Hazard Controls:  Prevention of exposure to bloodborne pathogen administrative controls include universal precautions, assignment of PPE, employee training, use of spill kits specifically designed for blood and body fluids, restricted access to waste collection points, and waste disposal procedures.

Biological Hazard:  The term biological hazard or biohazard is taken to mean any viable infectious agent that presents a risk, or a potential risk, to the well being of humans.

Blood borne Pathogens:  Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).

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

Contaminated Laundry:  Laundry, which 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.

Engineered Hazard Controls:  Prevention of exposure to bloodborne pathogens engineering controls include proper storage facilities and containers, syringes designed to prevent accidental needle sticks, autoclaves and disinfectant equipment.

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

Hazards:  Unprotected exposure to body fluids presents the possible risk of infection from a number of bloodborne pathogens notably Hepatitis and HIV.

Infection Control Plan:  The purpose of the Infection Control Plan is to protect the health and safety of the persons directly involved in handling the materials, college personnel and the public by ensuring the safe handling, storage, use, processing, and disposal of infectious medical waste.  This plan complies with OSHA best practices on blood borne pathogens.

Medical Wastes/Infectious Wastes:  All waste emanating from human or animal tissues, blood or blood products or fluids.  This includes used first aid bandages, syringes, needles, sharps; material used in spill cleanup and contaminated Personal Protective Equipment (PPE) or clothing.

Occupational Exposure:  Blood or body fluid contact from an injured or ill Employee to the affected Employee or injury by a contaminated sharp object.

Other Potentially Infectious Materials:  (1) The following human body fluids: 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; (2) Any unfixed tissue or organ (other than intact 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.

Personal Protective Equipment:  Specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard is not considered to be personal protective equipment.

Regulated Waste:  Liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

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 be protected as though such body fluids were infected with bloodborne pathogens.  All infectious/medical material are handled according to Universal Precautions.  The following universal precautions must be taken:

  1. Gowns, aprons, or lab coats must be worn when splashes of body fluid on skin or clothing are possible.
  2. Mask and eye protection are required when contact of mucosal membranes (eyes, mouth or nose) with body fluids is likely to occur (e.g. splashes or aerosolization).
  3. Resuscitation equipment, pocket masks, resuscitation bags, or other ventilation equipment must be provided to eliminate the need for direct mouth-to-mouth contact.
  4. Gloves must be made of appropriate disposable material, usually intact latex or vinyl. They must be used:
    1. When the employee has cuts, abraded skin, chapped hands, dermatitis, or the like.
    2. When examining abraded or non-intact skin of a patient with active bleeding.
    3. While handling blood or blood products or other body secretions during routine procedures.


  1. Employees Subject to Occupational Exposure: Assignments in which employees may be exposed to blood or other potentially infectious material (“OPIM”) may include health occupation faculty, faculty and coaches, and custodial/maintenance staff.  Employees with occupational exposure fall into one of two categories.
    1. Category 1 consists of those job classifications in which all employees may be expected to incur occupational exposure, regardless of frequency. Category 1 Occupations include:
      • Nurses
      • Athletic Coaches
    2. Category 2 consists of those job classifications in which some employees have occupational exposure. For Category 2 job classifications, tasks, which might pose the possibility of occupational exposure, are listed.  Category 2 Occupations include:
      • E. Faculty (If required to handle blood or OPIM (general first aid))
      • Faculty / Employees (If required to handle blood or OPIM (general first aid))
      • Custodians/Maintenance (If they have to handle blood-soaked towels, or required to clean up blood spills.)
    3. Category 3 consists of all other employees.
  2. Exposure Controls:
    1. Hand washing facilities are located in all restrooms and lab facilities.
    2. Personal protective equipment (PPE) is located in all Category 1 areas including:
      1. Canton Campus:
        • Athletic Director’s office and home games
        • Nursing
        • Reception desk
        • Votec main office
      2. Macomb Campus:
        • Business Office
        • Maintenance
        • Nursing
      3. Havana and Rushville Centers
        • Main office
    3. Maintenance staff is responsible for distribution and proper disposal of used gloves. Used disposable gloves are not to be washed or decontaminated for re-use.  Category 1 employees will ensure that personal protective equipment are worn whenever it is reasonably anticipated that an employee will have contact with blood or other potentially infectious materials.
    4. Sharps containers are available in the nursing lab, allied health skills lab, and maintenance office.
    5. Maintenance staff will assure thorough cleaning and decontamination of any blood spills by use of EPA registered germicide, or 10% bleach solution.
    6. In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious material, employees are not to eat, drink, apply cosmetics or lip balm, smoke or handle contact lenses.
    7. Regulated waste shall be placed in appropriate containers marked biohazard. Such containers are located in maintenance.
    8. All affected bins, pails, cans and similar receptacles shall be inspected and decontaminated by maintenance staff after every incident.
    9. Any broken glassware, which may be contaminated with blood or other potentially infectious materials, will not be picked up directly with the hands. The following procedure is used:
      1. Cleaning will be by broom and dust pan (decontaminated after use)
      2. Surface area decontaminated by maintenance staff
    10. Contaminated laundry and/or sharps will be handled as little as possible using the following process
      1. Immediate disposal of sharps soiled with blood or other potentially infectious materials in a biohazard sharps container is required.
      2. Category 1 or 2 employees using appropriate personal protective equipment will ensure that laundry, which has been soiled with blood or other potentially infectious materials, is properly bagged and labeled immediately with a biohazard label at the location where it was used and shall not be sorted or rinsed in the location of use. Soiled laundry will be handled using one of the following methods:
      3. The owner of the contaminated laundry may, with completion of appropriate release obtain possession of contaminated laundry. **See Appendix 5 for appropriate release form.
      4. The owner of the contaminated laundry may request Spoon River College properly dispose of contaminated laundry. In this case, the biohazard bag is delivered to the Human Resources Office.  The Human Resources Office will control billing procedures disposing of contaminated laundry.
  3. Provisions of Hepatitis B Vaccination:
    1. Pre-Exposure Vaccination: Hepatitis B vaccination is available to those persons determined to be at risk at no cost to the employee.  For employees in Category 1, the vaccine is offered within ten (10) working days of their initial assignment, which may involve the potential for occupational exposure to blood or other potentially infectious materials (OPIM).  Staff members who have already received the vaccine or wish to decline are required to sign a waiver (Appendix A).  Employees who later wish to have it may then have the vaccine provided at no cost to the employee.
    2. Post-Exposure Vaccination: All unvaccinated employees who are potentially exposed, are offered the vaccine within 24 hours by the Human Resources Office if the employee renders assistance in any situation involving the presence of blood or other potentially infectious materials.All incidents are to be immediately reported to the switchboard operator who will contact the appropriate staff.  A report (Exposure Incident Investigation Form) must be submitted to the Human Resources Office as soon as possible.The Human Resources Office will assure that the vaccine is offered and will maintain documentation of employee vaccination status.  Employees who decline the Hepatitis B vaccine will sign a waiver.  Employees who initially decline the vaccine but who later wish to have it may then have the vaccine provided at no cost to the employee by informing the Human Resources Office.
  4. Post Exposure Evaluation and Follow Up:
    1. Reporting an Exposure Incident: When employees incur an exposure incident, it is their responsibility to report the incident in writing (Exposure Incident Investigation Form) to the Human Resources Office.  The Human Resources Office has responsibility to maintain records of exposure incidents.
    2. Evaluation and Follow-up after an Exposure Incident: All employees who incur an exposure incident are offered by the Human Resources Office post-exposure evaluation and follow-up in accordance with the bloodborne pathogens standard.  The follow-up is conducted by a health care professional and will include the following:
      1. Documentation of the route of exposure and the circumstances related to the incident.
      2. If possible, the identification of the source individual and, if possible, the status of the source individual. The blood of the source individual is tested (after consent is obtained) for HIV/HBV infectivity.
      3. Results of testing of the source individual are made available to the exposed employee with the exposed employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual. The exposed employee is given the “Notice to Employees Involved in Occupational Exposure Incidents Involving Blood or Other Potentially Infectious Materials” and will verify that s/he has been informed about these laws by signing the Notice.
      4. Employee is offered the option of having their blood collected for testing of the employee’s HIV/HBV serological status. The blood sample is preserved for at least 90 days to allow the employee to decide if the blood should be tested for HIV serological status.  If the employee decides prior to that time, that testing is conducted, then the appropriate action can be taken and the blood sample discarded.
      5. The employee is offered post-exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service.
      6. The employee is given appropriate counseling 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 and to report any related experiences to the appropriate personnel.
      7. A written opinion shall be obtained from the health care professional who provides the post-exposure evaluation and shall be provided to the employee within fifteen (15) days of the completion of the evaluation. Written opinions are obtained in the following instances:
        • When the employee obtains the Hepatitis B vaccine, or
        • Whenever the employee receives a medical evaluation and follow-up following an exposure incident.
      8. There is a formal agreement between Spoon River College and a local health care professional for pre-exposure and post-exposure evaluations and treatment.
      9. The Human Resources Office has been designated to assure that the appropriate information is provided to the health care professional conducting the post-exposure evaluation, that the post-exposure evaluation is effectively carried out, and that the written opinion is prepared properly and provided to the employee.
      10. The Bloodborne Pathogens Committee is appointed by the President, as a permanent committee and is responsible for training personnel and reviewing all incident reports.
      11. This plan is reviewed by the Administration annually and updated 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.
  5. Record Keeping: All records required by the bloo borne pathogens standard are maintained by the Human Resources Office.  All provisions required by the standard was implemented by May 29, l993.
  6. Training:
    1. All Employees (unaffected employees):
      1. All supervisors must ensure that their staff is trained in proper work practices, the concept of universal precautions, and to contact maintenance personnel and/or custodial services who handle, store, use, process, or disposes of infectious medical wastes, should the need arise.
      2. Employees will receive an overview of the program requirements during new employee orientation.
    2. Category 1 and 2 Employees (affected employees): Training for Category 1 and 2 employees is conducted prior to initial assignment to tasks where occupational exposure may occur.  All Category 1 and 2 employees will receive annual refresher training.  The training is conducted by certified trainers.
    3. Workplace and Procedure Training: This type of training is required for maintenance staff, cafeteria staff, switchboard staff, specified part-time faculty, security guard.  Refresher training is conducted annually. All other employees are provided with a copy of the plan at the time of their orientation. Training for employees will include an explanation of:
      • the bloodborne pathogens standard.
      • epidemiology and symptomatology of bloodborne diseases.
      • modes of transmission of bloodborne pathogens.
      • this Exposure Control Plan, i.e., points of the plan, lines of responsibility, how the plan is implemented, etc.
      • procedures which might cause exposure to blood or OPIM at the workplace.
      • control methods which is used at the workplace to control exposure to blood or OPIM.
      • personal protective equipment available.
      • post-exposure evaluation and follow-up.
      • signs and labels used at the workplace.
      • hepatitis B vaccine availability.
      • the outline of the training material is located in the Human Resources Office.
      • all employees are required to sign an acknowledgment of training and procedures.


Document for posting: Personal Protective Equipment for Worker Protection against HIV and HBV Transmission
Document for posting: Bloodborne Pathogen Control