Policy No. 6700 Bloodborne Pathogens Exposure Control Plan

Bloodborne Pathogens Exposure Control Plan 

1. BOARD DIRECTIVE 

Cache County School District recognizes and is committed to providing a safe and healthful work environment for all CCSD employees and promotes safe work practices in an effort to minimize the incidence of illness and injury and to reduce occupational exposure to bloodborne pathogens that employees may encounter in their workplace. 

1. OVERVIEW OF EXPOSURE CONTROL PLAN 
2. The Director of Risk Management (Director) shall implement and maintain the District Exposure Control Plan (the Plan) and ensure work is conducted in compliance with the Plan. 
3. The Plan shall be reviewed and updated as necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. 
4. The Plan shall be made available, upon request for examination and copying to the Assistant Secretary and the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services. 
5. The Plan shall be designed to protect employees from health hazards associated with bloodborne pathogens; and provide appropriate treatment and counseling should an employee be exposed to bloodborne pathogens. 
6. The Plan shall be available to employees at any time. Employees at risk of occupational exposure shall be advised of the Plan and its availability during a special detailed education course and during yearly training. A copy of the Plan shall be kept at the District office and the principal’s office of each school. 
7. Employees are responsible for complying with the requirements of the Plan and shall consult with a supervisor when questions arise concerning bloodborne pathogens, and not underestimate the risk of exposure to bloodborne pathogens. 

III. EXPOSURE DETERMINATION 

1. Performance of the following tasks and procedures can result in occupational exposure for those employees who may be in contact with blood or other 

potentially infectious materials: handling of blood; 

• care of wounds or injuries; 
• disposal of regulated waste; 
• cleaning of contaminated surfaces; 
• administration of medication; 
• diapering; and 
• finger sticks. 

1. Exposure determination in the list of jobs identified below is based on occupational risks that may occur. All employees with the following job classifications (job titles are

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descriptive and do not indicate work level or grade) may experience occupational exposure to blood or other potentially infectious materials: 

• custodians; 
• playground assistants; 
• teacher assistants; 
• school nurses; 
• teachers; 
• secretaries; 
• principals and assistant principals; 
• counselors; 
• PARC staff; 
• bus drivers and bus assistant; 
• coaches and coaching assistants. 

1. METHOD OF COMPLIANCE 
2. General 

All employees shall observe “universal precautions” 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. 

1. B. Engineering and Work Practice Controls 

Engineering and Work Practice Controls shall be used to eliminate or minimize employee exposure to bloodborne pathogens. When a risk of occupational exposure remains after institution of these controls, personal protective equipment shall also be used. General Work Practice Controls include: 

1. Employees shall wash their hands with antibacterial soap and water immediately after removing gloves or other personal protective equipment and following contact of body areas with blood or other potentially infectious materials. 
2. Antiseptic hand cleanser and clean towels or towelettes shall be available for staff when hand washing facilities are not immediately available. Hands must be washed with soap and water as soon as feasible after use of hand cleanser or towelettes. 
3. Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is potential for exposure to 

bloodborne pathogens. 

4. Emergencies involving blood or other potentially infectious materials shall be handled in a way to minimize splashing, spraying, spattering, and generation of droplets. 
5. Injured persons should care for their wound as much as possible. 
6. Contaminated work surfaces or equipment shall be appropriately disinfected immediately or as soon as feasible when surfaces are overly-contaminated or after any spill of blood or other potentially infectious materials. 
7. Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed.

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1. PERSONAL PROTECTIVE EQUIPMENT 

When there is a risk of occupational exposure, appropriate personal protective equipment shall be readily accessible at the worksite at no cost to the employee. 

1. Gloves 
2. Protective disposable 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 non-intact skin, and when 

handling or touching contaminated items or surfaces. 

2. Disposable gloves shall not be washed or decontaminated for reuse. 
3. Hypo-allergenic gloves or other similar alternatives shall be available to 

employees allergic to gloves normally provided. 

4. Utility gloves may be decontaminated for reuse if the integrity of the glove 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. 
5. Masks, Eye Protection, and Face Shields 
6. Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious 

materials may be generated and eye, nose, or mouth contamination can be 

reasonably anticipated. 

1. Exception to Use of Protective Equipment 
2. An employee may choose, temporarily and briefly, under rare and extraordinary circumstances, to decline the use of protective equipment, if in the 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 investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future. 
3. GENERAL HOUSEKEEPING 

Maintaining schools in a clean and sanitary condition is an important part of this Plan. The following housekeeping/custodial procedures shall be implemented: A. Contaminated work surfaces shall be decontaminated with an appropriate disinfectant immediately after a spill or leakage occurs; 

1. Broken glass which may be contaminated shall never be picked up by hand even if gloves are worn. It shall be cleaned up using mechanical means, such as a brush and dustpan or tongs. The implements used must be cleaned and decontaminated if the glass container held blood or other potentially infectious material; 
2. All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for 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;

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1. Protective gloves shall be used when necessary in the correct manner (general rules - “If it’s wet and not yours - glove!”). 

VII. REGULATED WASTE 

Regulated waste that may be generated in school or District department facilities include, but is not limited to, used gloves, soiled laundry, sharps, bandages, and gauze saturated with blood or other potentially infectious materials. 

1. Regulated waste shall be kept in closed containers which can hold all contents without leakage during handling, storage, and transport; and are color-coded or labeled. B. Biohazard warning labels shall be used to mark all regulated waste if not placed in a red bag or coded in red or orange colors. 
2. Regulated waste disposal shall be in accordance with applicable state and local laws. 

VIII. CONTAMINATED LAUNDRY 

1. Contaminated laundry, which includes articles of clothing or linen contaminated with blood or other potentially infectious materials, shall be handled as little as possible with a minimum of agitation. B. Employees shall not take contaminated laundry home to clean. 
2. Contaminated laundry shall be bagged at the location of use, placed in color-coded or labeled bags, sorted, rinsed and laundered off-site. 
3. 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 which prevent soak-through and/or leakage of fluids to the exterior. 
4. Employees who handle contaminated laundry shall wear protective gloves and other appropriate personal protective equipment. 
5. Contaminated laundry shall be washed by an employee who has received bloodborne pathogen training, hepatitis B vaccine, and uses protective equipment as required by OSHA or a commercial laundry or independent contractor. 
6. HEPATITIS B VACCINATION 
7. Hepatitis B vaccination shall be made available, at no cost to the employee, after the employee has received 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. 
8. 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 employee may receive the vaccination at no cost to the employee. 
9. An employee who declines the vaccine shall sign a Hepatitis B Declination Form. D. Booster doses of the vaccine shall be provided if recommended by the U.S. Public Health Service at a future date.

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1. POST-EXPOSURE EVALUATION, TREATMENT, AND FOLLOW-UP A. Immediate Treatment and Reporting of Exposure Incident 
2. Following an exposure incident, the exposed employee must: 
3. immediately wash their wound(s) and/or skin with soap and water, 

and/or flush their mucous membranes with water; 

1. immediately report the exposure incident to their principal or supervisor; and c. with the assistance of the employee’s principal or supervisor, follow the steps outlined in the Occupational Exposure Checklist. 
2. Identification/Testing of Source Individual 
3. The principal/supervisor must attempt to identify the source individual and complete the Source Individual Information form. 
4. If they cannot identify the source individual, they must document the 

reason. 

1. If the source individual is identified, they must ask the individual if they are infected with HIV or HBV. 
2. If the source individual is known to be infected with HIV or HBV 

testing for the source individual’s status need not be repeated. 

1. If the source individual does not know if they are infected, their blood shall be tested as soon as feasible and after consent is obtained in order to 

determine HIV or HBV infectivity. 

1. Testing should be done at an approved Workers’ Compensation provider facility. 
2. The principal/supervisor shall provide a copy of the Source Individual 

Information form to the facility testing the source individual and inform the provider to: 

1. bill the source individual’s testing to the exposed employee’s Workers’ 

Compensation insurance claim; 

1. inform the exposed employee of the results of the source individual 

testing; 

iii. inform the healthcare provider evaluating the exposed employee of 

the results; and 

1. inform the source employee of the results and refer him/her for 

follow-up care, if needed. 

1. If consent is not obtained, the principal/supervisor shall document the 

refusal and immediately inform the Director who shall, in consultation 

with the Labor Commission, establish that legally required consent 

cannot be obtained or is not required by law. 

1. Healthcare Provider Information 
2. The District shall ensure the healthcare provider evaluating an employee after an exposure incident is provided with: 
3. a copy of the Information for Healthcare Provider form; 
4. the correct billing information for the Workers’ Compensation claim; 
5. a description of the exposed employee’s duties as they relate to the 

exposure incident;

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1. documentation of the route(s) of exposure and circumstances under 

which exposure occurred; 

1. the website for the OSHA Bloodborne Pathogens regulation; 
2. unless infeasible or prohibited by state or local law, identification and 

documentation of the source individual, including results of the source’s 

blood tests; and 

1. all medical records relevant to the appropriate treatment of the 

employee including vaccination status. 

1. Confidential Medical Evaluation, Blood Collection, and Baseline Testing 1. The District shall make immediately available to the exposed employee, a confidential medical evaluation and follow-up. 
2. The exposed employee’s blood shall be collected as soon as feasible and tested after consent is obtained at the time of the incident and three to six months later. 3. If the employee consents to baseline blood collection but does not give consent at the 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 baseline sample tested, such testing shall be done as soon as feasible. 
3. Should the employee refuse baseline testing for HIV or HBV and later test positive while employed by the District, they may not be eligible for workers compensation insurance benefits. 5. Post-exposure prophylaxis, when medically indicated, shall be offered to the exposed employee as recommended by the U.S. Public Health Service Guidelines. 
4. Healthcare Provider’s Written Opinion 
5. The Director shall obtain and provide to the employee a copy of the 

evaluating healthcare professional’s written opinion within fifteen (15) days of the completion of the evaluation. 

2. The written opinion shall be included in the employee’s confidential 

medical records. 

3. The written opinion shall include: 
4. whether Hepatitis B vaccination is recommended for the exposed 

employee and if the employee received the vaccination; 

1. that the employee has been informed of the results of the evaluation; and c. that the exposed employee has been informed of any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment. 
2. All other findings or diagnoses shall remain confidential and shall not be included in the written report. 
3. RECORDS 
4. Record of Exposure Incidents 
5. The District shall maintain an accurate record for each employee with 

occupational exposure, in accordance with 29 CFR § 1910.1020. These records shall include:

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1. the name and social security number of the employee; 
2. a copy of the employee’s Hepatitis B vaccination status including the 

dates of all the Hepatitis B vaccinations, anti-HBs test results, and any 

medical records relative to the employee’s ability to receive a 

vaccination, or signed declination statement; 

1. results of examinations, medical testing, and follow-up procedures; 
2. a copy of the healthcare professional’s written opinion; and 
3. a copy of the information provided to the healthcare professional about 

the exposure incident. 

2. These records are to be maintained separate from the employee’s personnel file and shall be kept confidential and shall not be disclosed or reported without the employee’s express written consent to any person within or outside the workplace except as required by law. 
3. These records shall be maintained for at least the duration of employment plus thirty (30) years in accordance with 29 CFR § 1910.1020. 
4. Training and Training Records 
5. Training records shall be kept for three (3) years from the date on which the training occurred and shall include the following: 
6. dates of training sessions; 
7. content or a summary of the training; 
8. names and qualifications of the trainers; and 
9. names and job titles of all persons attending the session. 
10. Records Access 
11. All records required to be maintained under this policy shall be made available upon request to: a. the OSHA Assistant Secretary and the Director for 

examination and copying; 

1. the employee who is the subject of the particular record; and 
2. anyone having written consent of the subject employee. 
3. Requests for records created and maintained under this policy shall be directed to the Director and shall be fulfilled within fifteen (15) working days. 

Definitions 

“Blood” means human blood, human blood components, and products made from human blood. “Bloodborne Pathogens” means 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), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). 

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

“Contaminated laundry” means laundry which has been soiled with blood or other potentially infectious materials. “Contaminated sharps” means 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. “Decontamination” means the use of physical or chemical

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means to remove, inactivate, or destroy bloodborne pathogens on a 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. 

“Engineering controls” means controls that isolate or remove the bloodborne pathogens hazard from the workplace. 

“Exposure incident” means 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. “Hand washing facilities” means a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines. 

“HBV” means hepatitis B virus. 

“HCV” means hepatitis C virus. 

“HIV” means human immunodeficiency virus. 

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

“Other Potentially Infectious Materials” means: (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. 

“OSHA” is the Occupation Safety and Health Administration, the main federal agency charged with enforcement of employee safety and health legislation. 

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

“Personal Protective Equipment” is specialized clothing or equipment worn by an employee for protection against a hazard. 

“Post-exposure Prophylaxis” means preventative procedures or treatment provided an exposed employee. “Regulated Waste” means 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 waste containing blood or other potentially infectious materials. 

“Source Individual” means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. “Universal Precautions” is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HCV, HBV, and other blood borne pathogens. 

“Work Practice Controls” means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., allowing an injured person to care for their own wound).

Legal References: 

Cache County School District Policy Series 6000: Finance and Operations 

29 CFR § 1910.1030 – Bloodborne pathogens 

Utah Code Ann. Title 34A, Chapter 6 - Utah Occupational Safety and Health Act Utah Code Ann. § 63A-4-204 - School District participation in Risk Management Fund. 

Synopsis: 

Approved by the Board of Education: October 25, 2018.

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