A4900.25 Bloodborne Pathogens Exposure Control


Type: Administrative
Related Policies: A4900
Linked Procedures:
Related Laws:
Related Standards:
HLC Criterion:



Shawnee Community College is committed to providing a safe environment for all students and staff.  The college developed an exposure control plan in accordance with the Occupational Safety and Health Administration Bloodborne Pathogens Standard (29CFR 1910.1030).  This plan includes the following:


OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials.  The exposure determination is made without regard to the use of personal protective equipment.  This exposure determination lists all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency.  The job classifications detailing staff which may incur occupational exposure to blood or other potentially infectious materials are outlined below:

Job Classification Task/Procedure
Maintenance Staff Bloodborne Pathogen Clean-Up
Coaching Staff Bloodborne Pathogen Clean-Up
Laboratory Instructors Bloodborne Pathogen Clean-Up


All contracted employees will have training directly from their employer.  (Security, custodial, etc.)



Compliance Methods:

Universal Precautions will be observed at this facility in order to prevent contact with blood or other potentially infectious materials.  All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual.

Engineering and work practice controls will be used to eliminate or minimize exposure to employees.  Where occupational exposure remains after implementing these controls, personal protective equipment shall also be used.  At this facility the following engineering controls will be used:

  • Handwash facilities
  • Eyewash stations
  • Biohazard labels
  • Step-on containers with biohazard bags

The above controls will be examined and maintained on a regular schedule.  The schedule for reviewing the effectiveness of the controls is as follows:

Handwash facilities: Daily
Eyewash stations: Weekly/Monthly
Step-on containers with biohazard bags (K1113 Lab): Daily

Handwashing facilities are readily available to the employees who incur exposure to blood or other potentially infectious materials.  Handwashing facilities are located:

  • Athletic training room
  • Food preparation area
  • Custodial storage rooms
  • Biology storage
  • Chemistry laboratory
  • Nursing laboratory
  • All restrooms
  • Cosmetology laboratory

In situations where handwashing facilities are not feasible (athletic fields), an antiseptic cleanser in conjunction with clean cloth/paper towels are provided.  If the alternatives are used then the hands are to be washed with soap and running water as soon as feasible.

After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water.  If employees incur exposure to their skin or mucous membranes then those areas shall be washed or flushed with water as appropriate or as soon as feasible.

All sharps shall be disposed of in a labeled container.


Personal Protective Equipment:

All personal protective equipment used will be provided without cost to employees.  Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials.  The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees’ clothing, 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.

Protective clothing will be provided to employees in the following manner:

Personal Protective Equipment Task
Non-Latex Gloves Treating cuts, abrasions, etc.
Protective Eyewear (with solid side shield) Cleaning up chemical spills or vomit
Disposable Barrier Apron Cleaning up chemical spills or vomit
Surgical Mask Cleaning up chemical spills or vomit


All personal protective equipment will be cleaned, laundered, and disposed of by the employer at no cost to employees.  All repairs and replacements will be made by the employer at no cost to employees.

All garments that are penetrated by blood shall be removed immediately or as soon as feasible.  All personal protective equipment will be removed before leaving the work area.  The following protocol has been developed to facilitate leaving the equipment at the work area:

All equipment will be disposed of in containers labeled biohazardous receptacles.

Gloves shall be worn where it is reasonably anticipated that employees may have contact with blood, other potentially infectious materials, non-intact skin, and mucous membranes.  Gloves will be available from the athletic training room, athletic medicine kits, food preparation area, custodial storage areas, biology lab, chemistry lab, nursing lab, and cosmetology lab.

Disposable gloves used at the facility are not to be washed or decontaminated for re-use and are to be 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.

Situations at this facility that would require such protection are as follows:

Cleaning up blood or any unidentifiable body fluids.

This facility will be cleaned and decontaminated according to the following schedule:

Any area contaminated with blood or other potentially infectious materials will be cleaned immediately to prevent further contamination.

Decontamination will be accomplished by using the following materials:

A solution which includes 10% bleach and 90% water and/or other approved solution.

All contaminated work surfaces will be decontaminated after completion of procedures, immediately or as soon as feasible after any spill of blood or other potentially infectious materials, as well as at the end of the work shift if surfaces may have become contaminated since the last cleaning.

All bins, pails, cans, or similar receptacles shall be inspected and decontaminated each week by the custodian assigned to the respective area.


Bio-hazard Regulated Waste Disposal:

Regulated waste shall be placed in labeled containers.  Such containers are located in the nursing lab.


Hepatitis B Vaccine:

All employees who have been identified as having exposure to blood or other potentially infectious materials will be offered the Hepatitis B vaccine, at no cost to the employee.  The vaccine will be offered within 10 working days of their initial assignment to work involving the potential for occupational exposure to blood or other potentially infectious materials unless the employee has previously had the vaccine or wishes to submit to antibody testing that shows the employee to have sufficient immunity.

Employees who decline the Hepatitis B vaccine will sign a waiver.

Employees who initially decline the vaccine but who later wish to have it while still covered under standard may then have the vaccine provided at no cost.

The Human Resource Officer will make certain annual training regarding bloodborne pathogens is provided whenever applicable.  The Hepatitis B vaccine will be administered by Southern Seven Health Department.


Post-Exposure Evaluation and Follow-Up:

When the employee incurs an exposure incident, it should be reported to the Human Resource Officer.

All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard.

This follow-up 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 will be tested (after consent is obtained for HIV/HBV infectivity).
  3. Results of testing of the source individual will be 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.
  4. The employee will be offered the option of having their blood collected for testing of the employee’s HIV/HBV 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 for HIV serological status.  However, if the employee decides before that time that testing will or will not be conducted, then the appropriate action can be taken and the blood sample discarded.
  5. The employee will be offered post-exposure prophylaxis.

Revised June 2, 2014


Change Log
Date Description of Change Governance Unit