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Bloodborne Pathogens Standard

Exposure Control Plan (ECP) for Bloodborne Pathogens Mich. Occupational Health Standard 325.70001 Federal OSHA (29 CFR 1910.1030)


Exposure Control Plan (ECP) for Bloodborne Pathogens   Mich. Occupational Health Standard 325.70001 Federal OSHA (29 CFR 1910.1030)


This document serves as the written procedures Bloodborne Pathogens Exposure Control Plan (ECP) for Hope College. These guidelines provide policy and safe practices to prevent the spread of disease resulting from handling blood or other potentially infectious materials (OPIM) during the course of work.

This ECP has been developed in accordance with the OSHA Bloodborne Pathogens Standard, Michigan Health Standard 325.70001 and  Federal OSHA 29 CFR 1910.1030. The purpose of this ECP includes:

  • Eliminating or minimizing occupational exposure of employees to blood or certain other body fluids.
  • Complying with OSHA's Bloodborne Pathogens Standard, 29 CFR 1910.1030.


The Department of Occupatational Health and Fire Safety is responsible for developing and maintaining the program. A copy of the plan may be reviewed by employees. It is located in the Occupational Health and Fire Safety Office(H&FS). In addition, the H&FS office is responsible for maintaining any records related to the Exposure Control Plan.

This plan is current as of 1/16/15

If after reading this program, you find that improvements can be made, please contact the H&FS office. We encourage all suggestions because we are committed to the success of our written ECP. We strive for clear understanding, safe behavior, and involvement from every level of the college.


We have determined which employees may incur occupational exposure to blood or OPIM. The exposure determination is made without regard to the use of personal protective equipment (i.e., employees are considered to be exposed even if they wear personal protective equipment).

Job Classes: Global Risk of Exposure

This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. At this facility the following job classifications are in this category:

  • Athletic Trainers, Athletic Training Students, Life Guards.
  • Biology Lab Directors
  • Health Clinic Staff
  • Housekeeping /Plumbers
  • Nursing Faculty, Lab/Media Coordinator, & Student Lab Assistants.
  • First Aid /CPR Providers - Campus Safety Officers.

Job Classes: Site Specific Risk of Exposure

The job classifications and associated tasks for these categories are explained in each departmental policy and procedure. Each of these departments has a site specific policy which can be obtained from the departmental representative. They are:
Athletic Trainer Kinesiology X7708
DeVos Field House
Biology Lab Director Biology X7722
Schaap Science Center
Operations Manager Physical Plant X7835
Physical Plant Office
Lab Coordinator Nursing Dept X7422
Schaap Science Center
Director of Campus Safety Campus Safety X7771
Campus Safety


  1. This plan includes an overview and method of implementation for departmental site specific requirements of this standard.

  2. Universal precautions techniques developed by the Centers for Disease Control and Prevention (CDC) will be observed at this facility to prevent contact with blood or OPIM. All blood or OPIM will be considered infectious regardless of the perceived status of the source individual.


  1. Engineering and work practice controls will be used to eliminate or minimize exposure to employees at this facility. Where occupational exposure remains after institution of these controls, employees are required to wear personal protective equipment. At this facility the following engineering controls are used:
    • Placing sharp items (e.g., needles, scalpels, etc.) in puncture-resistant, leakproof, labeled containers.
    • Performing procedures so that splashing, spraying, splattering, and producing drops of blood or OPIM is minimized.
    • Removing soiled PPE as soon as possible.
    • Cleaning and disinfecting all equipment and work surfaces potentially contaminated with blood or OPIM. Note: We use a solution of 1/4 cup chlorine bleach per gallon of water which should be used to wipe down the surface and allowed to air dry.
    • Towelettes or hand cleanser where handwashing facilities are not available.
    • Prohibition of eating, drinking, smoking, applying cosmetics, handling contact lenses, and so on in work areas where exposure to infectious materials may occur.
    • Use of leak-proof, labeled containers for contaminated disposable waste or laundry.
    • Use of protective gloves in all instances of handling raw sewage.

    The above controls are examined and maintained on a regular schedule. Each department containing category A employees has specific departmental plans, containing specific procedures, planning, and equipment that shall be consulted and understood by the effected employees on the above listed controls.

  1. Handwashing facilities are available to employees who have exposure to blood or OPIM. Sinks for washing hands after occupational exposure are near locations where exposure to bloodborne pathogens could occur. At Hope College handwashing facilities are located:

    • In any public restroom located on the campus of Hope College.

  2. When circumstances require handwashing and facilities are not available, either an antiseptic cleanser and paper towels or antiseptic towelettes are provided. Employees must then wash their hands with soap and water as soon as possible. Employees can find these hand-washing supplies:

    • From their supervisors.

  3. Supervisors make sure that employees wash their hands and any other contaminated skin after immediately removing personal protective gloves, or as soon as feasible with soap and water.

  4. Supervisors also ensure that if employees' skin or mucous membranes become contaminated with blood or OPIM, then those areas are washed or flushed with water as soon as feasible following contact.

  1. Hope College requires that equipment which has become contaminated with blood or OPIM must be decontaminated before servicing or shipping as necessary unless the decontamination of the equipment is not feasible. Our procedures for equipment decontamination are as follows:

    • Flush equipment with a bleach/water solution @ 10% Bleach and allow to air dry.
    • Use of other products manufactured to kill HBV or HIV virus.


  1. All personal protective equipment (PPE) used at this facility is provided without cost to employees. PPE is chosen based on the anticipated exposure to blood or OPIM. The protective equipment is 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 under normal conditions of use and for the duration of time which the protective equipment will be used.

  2. Hope College makes sure that appropriate PPE in the appropriate sizes is readily accessible at the work site or is issued without cost to employees by: Contacting the Health and Fire Safety office at X7999

  3. Synthetic, powder-free gloves, glove liners, powderless gloves, or other similar alternatives are readily accessible to those employees who are allergic to the gloves normally provided.

  4. We purchase (when consumable), clean, launder, and dispose of personal protective equipment as needed by:

    • All contaminated PPE which cannot be cleaned such as gloves must be placed in (red) Bio-hazard bags and secured in an area not accessible to the general public. Bags can be brought over to the Dow Center Health Clinic for disposal.

    • Items needing laundering can be brought over to the Dow Center Equipment room to be laundered. All repairs and replacements are made by Hope College at no cost to employees.

  5. Employees must remove all garments which are penetrated by blood immediately or as soon as possible. They must remove all PPE before leaving the work area. When PPE is removed, employees place it in a designated container for disposal, storage, washing, or decontamination. Employees may not bring contaminated laundry home.

  6. Employees must wear gloves when they anticipate hand contact with blood, OPIM, nonintact skin, and mucous membranes; when handling or touching contaminated items or surfaces. Disposable gloves used at this 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. Utility gloves may be decontaminated for re-use provided that the gloves are not torn, punctured, or when their ability to function as a barrier is compromised.

    • Synthetic, powder-free gloves , glove liners, powderless gloves, vinyl gloves or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.

  7. Employees must wear masks in combination with eye protective devices, such as goggles or glasses with solid side shield, or chin length face shields, whenever splashes, splatter, or droplets of blood or OPIM may be generated and reasonably anticipated to contaminate eye, nose, or mouth. Those situations and the corresponding eye and face protection include:

    • Contact your supervisor or look at your departmental policy.


  1. All bins, pails, cans, and similar receptacles must be inspected and decontaminated on a regularly scheduled basis: Each department should include in their site specific plans whom and how often this is to be done.

    • Contaminated equipment should be kept separate from other equipment. Decontamination should be done daily or as needed.

  2. Additional housekeeping requirements to prevent the spread of bloodborne pathogens include:

    • Broken glassware that may be contaminated shall not be picked up directly with hands. It shall be cleaned up using mechanical means and disposed of in closable, leakproof, puncture-resistant, disposable containers.


Medical Wastes should only be handled by persons who have been trained in the Bloodborne Pathogen Standard.  Employees designated with the responsibility of handling medical waste must follow the handling recommendations noted below.

What goes in the red bag?

  1. Generally, these DO go into a Stericycle red bag:

    • Visibly bloody gloves, plastic tubing, or personal protective equipment (PPE)
    • Gauze, bandages or other items saturated with blood
    • Securely closed disposable sharps containers

  2. Special handling, marking and local regulations may apply to these:

    • Certain pathological waste
    • Trace chemotherapy

  3. These DON’T go in the Stericycle red bag:

    • Medications

  4. DON’T discard these in the red bag:

    • Loose sharps (they go in sharps containers)
    • Hazardous and chemical waste
    • Radioactive waste
    • Fixatives and preservatives
    • Biotech or food processing waste that does not contain a potentially infectious agent
    • Household waste, food, paper products, and other medical solid waste (unless potentially infectious)

 How do I package my red bag medical waste?

Medical waste generators are legally responsible for packaging their waste.

Step 1: Line your container with the red bag prior to use.
Step 2: Tie the bag when the container is full. Each bag must be hand-tied by gathering and twisting the neck of the bag.

Step 3: Secure the lid on the container. Make sure all closure and/or locking mechanisms are engaged. Red bags must not be visible once the container is closed.

Step 4: Check the containers markings. Ensure that federal markings (biohazard symbol, this-side-up-arrows, regulated medical waste, N.O.S., and UN number) are present. Ensure you’re complying with your individual state regulations. If unsure of your state regulations, check with your Stericycle representative: 866.783.9816.  Improperly packaged containers or damaged containers will be denied pickup or returned to the customer.

What Goes in the Sharps Disposal Container?

Sharps include, but aren’t limited to, needles, lancets, syringes, broken glass, scalpels, culture slides, culture dishes, broken capillary tubes, broken rigid plastic, and exposed ends of dental wires. Laboratory slides and cover slips contaminated with infectious agents. Our sharps disposal services has a more    complete description of sharps waste.

How do I package my sharps waste?

Step 1: Place sharps in a puncture-resistant container designed for sharps waste. Do not allow loose sharps in any waste container other than the sharps container.

Step 2: Securely close the container.

Step 3: Place disposable containers in the red bag waste or schedule for pickup.

When handling regulated wastes, other than contaminated needles and sharps, we make sure it is:

Placed in containers which are closeable, constructed to contain all contents, and prevent fluid leaks during handling, storage, transportation, or shipping.  Containers can be obtained from the Health and Fire Safety office. X7999.

Labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

: Disposal of all regulated waste is in accordance with applicable United States, state and local regulations. Regulated medical waste is picked up at the Dow Center Health Clinic, A Paul Schaap Science Center, and the DeVos Field Hse  by a licensed medical waste hauler. Hope College uses Stericycle, Inc. 1040 Market St. SW Grand Rapids, MI 49503 to pick-up it's medical waste. Phone (616) 454-9405. All medical pick-ups can be scheduled by calling the Occupational Health and Fire Safety office at X7999.


Laundry contaminated with blood or OPIM is handled as little as possible. Such laundry is placed in appropriately marked (biohazard labeled, or color coded red bag) bags at the location where it was used. Such laundry is not sorted or rinsed in the area of use.

Employees must remove all garments which are penetrated by blood immediately or as soon as possible. They must remove all PPE before leaving the work area. When PPE is removed, employees place it in a designated
container for disposal, storage, washing, or decontamination. Employees may not bring contaminated laundry home.

The contaminated laundry must be transported to the Dow Center Equipment Room and turned over to the Physical Education and Athletic Equipment Manager for washing. The Hope College Athletic Equipment Manager is Gordon Vander Yacht X7917.


  1. Hope College ensures that bloodborne pathogens trainers are knowledgeable in the required subject matter. We make sure that employees covered by the bloodborne pathogens standard are trained at the time of initial assignment to tasks where occupational exposure may occur, and every year thereafter by the following methods:

    • Video training program
    • Supervisor information and training in the work area and review of site specific policies and procedures.

  2. Training is tailored to the education and language level of the employee, and offered during the normal work shift. The training will be interactive and cover the following:

    • The standard and its contents.
    • The epidemiology and symptoms of bloodborne diseases.
    • The modes of transmission of bloodborne pathogens.
    • Hope College Bloodborne Pathogen ECP, and a method for obtaining a copy.
    • The recognition of tasks that may involve exposure.
    • The use and limitations of methods to reduce exposure, for example engineering controls, work practices and personal protective equipment (PPE).
    • The types, use, location, removal, handling, decontamination, and disposal of PPE
    • The basis of selection of PPEs.
    • The Hepatitis B vaccination, including efficacy, safety, method of administration, benefits, and that it will be offered free of charge.
    • The appropriate actions to take and persons to contact in an emergency involving blood or OPIM.
    • The procedures to follow if an exposure incident occurs, including the method of reporting and medical follow-up.
    • The evaluation and follow-up required after an employee exposure incident.
    • The signs, labels, and color coding systems.

    All trained employees must sign a Document of Training sign up sheet that is dated and indicates the training received and the name and title of the instructor. A copy of this sign up sheet should be filed with the Health and Fire Safey office at 178 East 11th street Holland, MI 49423. (See Document of Training record.)

  3. Additional training is provided to employees when there are any changes of tasks or procedures affecting the employee's occupational exposure. Employees who have received training on bloodborne pathogens in the 12 months preceding the effective date of this plan will only receive training in provisions of the plan that were not covered.

  1. Training records shall be maintained for three years from the date of training. The following information shall be documented:

    • The dates of the training sessions;
    • An outline describing the material presented;
    • 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 kept in the employees file at the Human Resources Office for three years. A copy of the training record shall be forwarded to the Occupational Health and Fire Safety office (See Document of Training Record.)

  2. Medical records shall be maintained in accordance with OSHA Standard 29 CFR 1910.20. These records shall be kept confidential, and must be maintained for at least the duration of employment plus 30 years. The records shall include the following:

    • The name and social security number of the employee.
    • A copy of the employee's HBV vaccination status, including the dates of vaccination.
    • A copy of all results of examinations, medical testing, and follow-up procedures.
    • A copy of the information provided to the health care professional, including a description of the employee's duties as they relate to the exposure incident, and documentation of the routes of exposure and circumstances of the exposure.
    • Medical records on vaccinations and post exposure follow-ups will be kept at the Dow Center Health Clinic 168 East 13th street Holland, MI 49423,  PH 395-7585


All employee records shall be made available to the employee in accordance with 29 CFR 1910.20. All employee records shall be made available to the Assistant Secretary of Labor for the Occupational Safety and Health Administration and the Director of the National Institute for Occupational Safety and Health upon request.


  1. Hope College offers the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure to bloodborne pathogens, and post exposure follow-up to employees who have had an exposure incident.

  2. All medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post-exposure follow-up, including prophylaxis are:

    • Made available at no cost to the employee.
    • Made available to the employee at a reasonable time and place.
      1. Hepatitus B Vaccinations at the Holland Medi Center. 616-392-5222 Monday-Friday 7:30 AM to 5:30 PM.  Contact the Health and Fire Safety Office for an appointment, X7999 or 616-395-7999
      2. Post exposure follow-up and prophylaxis at the Holland Medi Center, 335 120th Ave Holland, MI  PH 392-5222  6:30 AM to 7:30 PM. After 7:30PM  Holland Community Hospital PH394-3202.
      3. Students (Non-employee) shall go to the Dow Center Health Clinic for post exposure follow-up and prophylaxis. After hour exposures can be treated by contacting the physicians exchange at PH392-8035.
    • 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 the recommendations of the U.S. Public Health Service.

  3. All laboratory tests are conducted by an accredited laboratory at no cost to the employee. Hepatitis B vaccination is made available:

    • After employees have been trained in occupational exposure (see Information and Training).
    • Within 10 working days of initial assignment.
    • To all employees who have occupational exposure unless a given 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.

  4. Provider documented proof of Hepatitis B vaccination status is required to be on file with the current employer. Each department should keep a record on file of their employees vaccination record. A copy can be sent to the Dow Center Health Clinic.

  5. 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 vaccination will be made available. All employees who decline the Hepatitis B vaccination offered must sign the OSHA-required waiver indicating their refusal. (See Hepatitis B Vaccination Declination Form)

  6. If a routine booster dose of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster doses will be made available at the Dow Center Health Clinic. Current CDC guidelines recommends that employees who have ongoing contact with patients or blood and are at on going risk for injuries with sharp instruments or needlesticks be tested for antibody to Hepatitis B surface antigen one to two months after the completion of the three-dose vaccination series. Employees who do not respond to the primary vaccination series must be revaccinated with a second three-dose vaccine and retested. Non-responders must be medically evaluated.

    Antibody testing and further vaccinations (if negative for antibodies) are now required for people who do direct patient care and give injections or use contaminated sharps.


  1. All exposure incidents are reported, investigated, and documented. When the employee is exposed to blood or OPIM, the incident is reported to their:

  2. When an employee is exposed, he or she will receive a confidential medical evaluation and follow-up.

  3. Collection and testing of blood for HBV and HIV serological status will comply with the following:

    • The exposed employee's blood is collected as soon as possible and tested after consent is obtained;
    • 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.

  4. All Hope College employees who incur an exposure incident will be offered post-exposure evaluation and follow-up according to the OSHA standard. All post exposure follow-up will be performed by the Holland Medi Center located at 175 Waverly Road Holland, MI 49423. The Holland Medi Center is open Monday through Friday from 6:30 AM to 7:30 PM.

    Exposure incidents occurring after hours should proceed to Holland Hospital Emergency Department and check in with the Triage Nurse. The Triage Nurse will send the employee to Prime Care during normal hours Monday through Friday from 12 Noon - 11:30 PM. Exposures that occur after hours will be handled by the Emergency Department.

    Campus Safety should be contacted on all exposure incidents. They will transport or obtain transportation for the exposed individual to the appropriate facility. Call X911 from any campus phone.

  5. The health care professional responsible for the employee's post-exposure medical evaluation is provided with the following:

    • A copy of the Post Exposure Evaluation and Follow-up Report -(See post exposure evaluation and follow-up report.)
    • Results of the source individuals blood testing, if available.
    • All medical records relevant to the appropriate treatment of the employee including vaccination status.

  6. The treating facility for post exposure incidents obtains and provides the employee with a copy of the evaluating health care professional's written opinion within 15 days of the completion of the evaluation. They will assign a follow-up person for counseling to the employee. The health care professional's written opinion for HBV vaccination must be limited to whether HBV vaccination is indicated for an employee, and if the employee has received such vaccination.

  7. The health care professional's written opinion for post-exposure follow-up is limited to the following information:

    • A statement that the employee has been informed of the results of the evaluation.
    • A statement that the employee has been told about any medical conditions resulting from exposure to blood or OPIM which require further evaluation or treatment.

    Note: All other findings or diagnosis shall remain confidential and will not be included in the written report.