Chapter 6 – Bloodborne Pathogen Exposure Control Plan

B. Appendices

  • Appendix 1 – Job Titles with Reasonably Anticipated Exposure to Blood or Other Potentially Infectious Materials (OPIM):
  • Appendix 2 – WSU Health Care Professional’s Written Opinion for Hepatitis B Vaccination Form
  • Appendix 3 – WSU Hepatitis B Vaccination Declination Form
  • Appendix 4 – WSU Health Care Professional’s Opinion for Post Exposure
  • Evaluation Form
  • Appendix 5 – WSU Health Care Professional’s Opinion for Post-Exposure Follow-Up Form

C. Purpose

This plan intends to eliminate or reduce employee’s exposure to blood borne pathogens. Bloodborne pathogens are microorganisms that may be present in human blood and other potentially infectious materials (OPIM) e.g., semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures and can cause disease in humans. These include, but are not limited to, Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV).

D. Scope

This exposure control plan covers EHS employees designated by the department as having reasonably anticipated occupational exposure to human blood or OPIM.

E. Responsibilities


  • Identify work activities with potential exposure to BBP or OPIM.
  • Require the previously identified employees familiarize themselves with this APP chapter.
  • Offer employees the HBV vaccine within 10 days of assignment to tasks with potential exposure.
  • Provide employees BBP training within 10 days of assignment to tasks with potential exposure.
  • Provide employees Personal Protective Equipment (PPE), for PPE selection and training information, please see this APP’s PPE chapter.
  • Evaluate employee adherence to BPP policy and initiate corrective action when necessary e.g., additional training and/or disciplinary action.
  • Arrange for employees to visit the emergency room immediately after a needle stick or other suspected exposure to blood or OPIM breaking the skin barrier.


  • Immediately inform their supervisor when (previously unidentified) tasks present potential BBP exposure.
  • Familiarize themselves with this APP chapter.
  • Receive the HBV vaccine per health care provider’s recommendations, or sign the HBV vaccine declination form provided in Appendix 3.
  • Attend and participate in BBP training.
  • Wear PPE and adhere to BBP policies and procedures. Employees not conforming to BBP policy may be subject to disciplinary action.
  • Visit the emergency room immediately after a needle stick or other suspected exposure to blood or OPIM breaking the skin barrier.

F. Training

Employees that may be assigned to clean-up of blood or OPIM or with a reasonable expectation of exposure must understand the contents of this APP chapter and receive BBP training upon initial employment (or within 10 days of assignment to tasks with exposure potential) and on an annual basis.

Training will include SPPM section S80.86, University BBP Safety Policies and Procedures. Training and methods will be evaluated on an annual basis to ensure best possible practices.

G. Requirements

Employees designated as having reasonably anticipated occupational exposure to BBP are to follow the universal precautions.  Universal precautions are an approach to infection control where all human blood and OPIM are treated as if known to be infected with BBP.  Accordingly, employees will use appropriate PPE, work practice controls, and engineering controls to eliminate or reduce their exposure.

H. Personal Protective Equipment

PPE provides a barrier to prevent employees from contacting human blood or OPIM. PPE is considered suitable if it does not permit blood or OPIM to pass through or reach the person’s skin, personal clothing, eyes, mouth or other mucous membranes under normal conditions of use. PPE includes disposable or other suitable gloves, eye protection, face masks, CPR masks, and coveralls. Disposable gloves should be replaced every six months. Refer to APP Chapter 11 for additional information on PPE.

PPE must be worn when it is reasonably anticipated that employees may have contact with blood or OPIM.

Disposable (single use) gloves will be replaced as-soon-as possible if they are torn, punctured, or when their ability to function as a barrier is compromised.  Nitrile gloves are available for employees who are allergic to latex gloves.

Reusable latex and nitrile utility gloves are also available for use, when work activities warrant additional protection. Personnel receive glove donning, doffing, inspection and decontamination training.

Splash resistant goggles and face masks must be worn whenever there is potential for splashes, spray, spatter, or droplets of blood or OPIM. CPR masks or similar barriers are required when performing CPR.

I. Work Practice Controls

The following work practices are used to reduce the potential for employee exposure to BBP:

  • Whenever possible, the injured person should self-administer first-aid and clean up any human blood or OPIM and contaminated waste resulting from the injury.
  • Employees wash their hands with soap and running water immediately or as-soon-as possible after removing gloves and/or other personal protective equipment.
  • Employees wash their hands and any other exposed skin with soap and water, or flush mucous membranes with water for fifteen minutes immediately or as-soon-as possible following contact with blood or OPIM.
  • Eating, drinking, using tobacco products, applying cosmetics, or lip balm, and handling contact lenses are prohibited in areas where blood or OPIM are present.
  • Employees identified in Appendix 1 and trained in BBP cleanup adhere to the following Spill Cleanup Procedures. All other employees promptly contact Facilities Services Dispatch (335-9000) to report blood/OPIM spills. Dispatch notifies Custodial Services who will evaluate the spill and, if possible, clean it up. If the spill is too large or in an area not served by Custodial Services, Dispatch notifies WHITCOM at 911 for assistance. Contaminated surfaces or equipment must be disinfected with either a commercially available disinfectant or a 1:10 dilution of household bleach. Diluted bleach solutions should be prepared for each use and not stored, which could affect the solution’s potency.

J. Spill Cleanup Procedures

EHS personnel with job titles listed in Appendix 1 may be required to respond to blood spills.  The following procedures must be followed as circumstances allow.  BBP spill training should be utilized when the situation requires an adaptation of the procedure to the specific circumstance encountered.

  • Obtain as much information as possible, including:
    • Spill location,
    • Area affected by the spill (materials and approximate square footage,
    • Contact person and contact information,
    • Names and contact information of other respondents.

Note: EHS personnel will not respond to cleanup spills associated with violent acts e.g. murder, suicide. EHS assistance may be requested to contain the area.

  • Coordinate with other responders and obtain spill cleanup materials (see below) and arrange to meet at a location where cleanup activities can be staged.
  • At least one respondent should report to the EHS building to get the appropriate cleanup materials and a response bag with PPE located in basement room B-19.
    • Gather and mix disinfectants needed,
    • Additional cleanup materials as needed:
      • Absorbent matting,
      • Brush and dust pan,
      • Sharps grabbing tool,
      • Sharps container,
      • Disinfectant,
      • Large pump sprayer,
      • Biohazard bags, and/or
      • Additional PPE.
  • Report to the response site and coordinate with the contact people on-site to assess the situation more thoroughly.
  • Cordon off the spill area to prevent the public from contacting the area if necessary.
  • Don PPE.
  • Take care to avoid spreading contamination, splashing, or aerosolizing blood or OPIM.
  • If there are sharps, sweep these up with a broom and dust pan or use the sharps grabbing tool and dispose in a sharps container.
  • Cover the spill with absorbent pads starting on the outside and working in.
  • Saturate the absorbent pads and blood with disinfectant.
  • Allow sufficient time for the disinfectant to act upon the BBP (fifteen minutes for 1:10 bleach).
  • Pick the spill cleanup materials pads and place them in garbage bags.
  • Wipe up all disinfectant and cleanup materials, placing them in waste bags.
  • Contaminated materials that cannot be disinfected must be placed in biohazard bags and disposed as biohazardous waste. See section L. Disposal of Items Contaminated with Blood/OPIM.
  • Disinfected material must be double bagged and thrown in a dumpster.
  • Do not use biohazard bags for decontaminated items.

K. Engineering Controls

Engineering controls separate bloodborne pathogens from workers.  The following engineering controls will be used:

  • Use “grabbers” or a broom and dustpan to pick up sharp objects;
  • Use long handled mops should be used to clean up liquids;
  • Use barricades, caution tape, door locks, or ask others to help keep unauthorized people from entering any area potentially contaminated with blood or OPIM.

L. Disposal of Items Contaminated with Blood/OPIM

First Aid Procedures

All visibly contaminated or potentially contaminated items such as gloves, gauze and bandages will be placed and disposed of in leak-proof, puncture-resistant containers that are marked with orange-red labels bearing the word “Biohazard” and the biohazard symbol in contrasting color. Contact Facilities Operations Waste Management at 335-9075 or 335-4530 for instructions in disposing of a biohazard bag.  Do not dispose of contaminated or potentially contaminated items or biohazard bags in regular waste receptacles.

Each first-aid kit will be provided with a biohazard bag for disposal of visibly contaminated or potentially contaminated items such as gloves, gauze, and bandages.  Biohazard bags are available through WSU Central Stores (3354583).

M. Hepatitis B Virus Vaccinations

All employees covered by this plan are to be offered the Hepatitis B vaccination series after training and within 10 days from the start of tasks with occupational exposure to human blood or OPIM. The vaccinations are provided at no cost to the employee.

Employees in the bloodborne pathogen program must be evaluated by a health care professional as to their need for a hepatitis B vaccination.  The WSU’s Health Care Professional’s Written Opinion for Hepatitis B Vaccination Form (Appendix 2) must be completed and returned to HRS within 15 days of the employee’s evaluation.

Prescreening of employees (pre-vaccine blood titers) shall not be a condition for beginning the Hepatitis B vaccination series.  However, Health Care

Professionals may recommend a post vaccine antibody titer (Anti-HBs) to assure the efficacy of the immunization.

Employees who decline vaccination must sign the WSU Hepatitis B Declination Form (Appendix 3) indicating they understand the risks of not receiving immunization. This decision to refuse the vaccination can be reversed at any time if the employee still has occupational exposure to bloodborne pathogens.

Employees who provide first-aid do not need to be offered the Hepatitis B vaccination until after an exposure incident.  An exposure incident means a specific injection, mucous membrane or non-intact skin contact with blood or OPIM while providing first-aid.  Contact EHS (335-3041) for more information.

N. Post Exposure Follow-Up

All employees who may have been exposed to human blood or OPIM should immediately wash the contaminated area with plenty of soap and running water.  Employees with mucous membrane exposure should rinse with water for fifteen minutes.

The employee should seek medical attention as-soon-as possible preferably within two hours.  The employee or the employee’s supervisor completes the WSU Health Care Professional’s Opinion for Post-Exposure Evaluation Form

(Appendix 4).  The completed form is to be provided to the Health Care

Professional.   The Health Care Professional is also provided and completes the WSU Health Care Professional’s Opinion for Post-Exposure Follow-Up Form (Appendix 5).

An Incident Report is to be completed with the following information:

  • A description of the exposed employee’s job duties at the time of the exposure.
  • Documentation of the routes of exposure

O. Annual Review

This exposure control plan will be reviewed annually as part of an overall safety program review, 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.