Exposure Control Plan (ECP) for Bloodborne Pathogens


This document serves as the written procedures Bloodborne Pathogens Exposure Control Plan (ECP) for Principia. 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, 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.

Administrative Duties

The Workplace Safety Director, is responsible for developing and maintaining the program. A copy of the plan may be reviewed by employees. It is located in the corporate office with the written safety & health program. In addition, the Safety Director, or designee, is responsible for maintaining any records related to the Exposure Control Plan.

If after reading this program, you find that improvements can be made, please contact the Safety Director, or designee. 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 company.

Exposure Determination

We have determined that all 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).

Further, should any body fluids be encountered, our employees are directed to use "Universal Precautions", and assume all bodily fluids are potentially infectious.

Compliance Strategies

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

Engineering and Work Practice Controls

Engineering and work practice controls will be used to eliminate or minimize exposure to employees by this company. Where occupational exposure remains after institution of these controls, employees are required to wear personal protective equipment. At this company the following engineering controls are used:

  • Placing sharp items (e.g., needles, scalpels, etc.) in puncture-resistant, leak proof, 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.
  • Thorough hand washing with soap and water immediately after providing care or provision of antiseptic towelettes or hand cleanser where hand washing 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.

The above controls are examined and maintained on a regular schedule for effectiveness.

Hand washing Facilities

Hand washing 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.

When circumstances require hand washing 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.

Supervisors must ensure 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. Supervisors must 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.

Work Area Restrictions

In work areas where there is a reasonable likelihood of exposure to blood or OPIM, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or OPIM are present.

Mouth pipetting/suctioning of blood or OPIM is prohibited. All procedures involving blood or other potentially infectious materials will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or OPIM.

Personal Protective Equipment

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.

PRINCIPIA College makes sure that appropriate PPE in the appropriate sizes is readily accessible at the work site or is issued without cost to employees.

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

  • All garments which are penetrated by blood shall be removed immediately or as soon as feasible. All PPE will be removed prior to leaving the work area. When PPE is removed, it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.
  • All repairs and replacements are made by PRINCIPIA College.
  • 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 must wear gloves when they anticipate hand contact with blood, OPIM, non-intact 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.

Eye and Face Shields

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.

Handling Regulated Wastes

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

Note: Disposal of all regulated waste is in accordance with applicable Unites States, state and local regulations.

Information and Training

PRINCIPIA 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 through safety briefings, annual training, or staff meetings.

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.
  • PRINCIPIA 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's.
  • The basis of selection of PPE's.
  • 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.

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. Training shall be conducted annually


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.

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 healthcare 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.


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.

Transfer of Records

If this facility is closed or there is no successor employer to receive and retain the records for the prescribed period, the Director of the NIOSH shall be contacted for final disposition.

Evaluation and Review

This program and its effectiveness is reviewed every year and updated as needed.

Hepatitis B Vaccination Program

PRINCIPIA 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.

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.
  • Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional.
  • Provided according to the recommendations of the U.S. Public Health Service.

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.

Participation in a pre-screening program is not a prerequisite for receiving Hepatitis B vaccination. 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.

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.

Post-Exposure Evaluation and Follow-Up

All exposure incidents are reported, investigated, and documented. When the employee is exposed to blood or OPIM, the incident is reported to the Safety Director, or designee. When an employee is exposed, he or she will receive a confidential medical evaluation and follow-up, including at least the following elements:

  • Documentation of the route of exposure, and the circumstances under which the exposure-occurred.
  • Identification and documentation of the source individual, unless it can be established that identification is infeasible or prohibited by state or local law.
  • The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, (enter your answer) establishes that legally required consent cannot be obtained. When the source individual's consent is not required by law, the source individual's blood, if available, will be tested and the results documented.
  • When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated.
  • Results of the source individual's testing are made available to the exposed employee, and the employee is informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

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.

All 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 contracted healthcare professionals.

The healthcare professional responsible for the employee's Hepatitis B vaccination is provided with the following:

  • A copy of 29 CFR 1910.1030.
  • A written description of the exposed employee's duties as they relate to the exposure incident.
  • Written documentation of the route of exposure and circumstances under which exposure occurred.
  • Results of the source individuals blood testing, if available.
  • All medical records relevant to the appropriate treatment of the employee including vaccination status.

PRINCIPIA College obtains and provides the employee with a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation.

The healthcare 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.

The healthcare 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.

Labels and Signs

Biohazard labels are affixed to containers of regulated waste, refrigerators and freezers containing blood or OPIM, and other containers used to store, transport or ship blood or OPIM. The universal biohazard symbol is used. The label is fluorescent orange or orange-red. Red bags or containers may be substituted for labels.

Blood products that have been released for transfusion or other clinical uses are exempted from these labeling requirements.

The information and requirements of this written plan are presented to employees in annual training, on the job safety briefs, or at staff meetings.

Annual Program Evaluation

This program has been evaluated on the below noted date. All facets of the program have been included in the evaluation. The program meets or exceeds the purpose, policies, and procedures as outlined in this written program.

________________________________________   ____________________
Safety Director, or Designee,   Date:
________________________________________   ____________________
Safety Director, or Designee,   Date:
________________________________________   ____________________
Safety Director, or Designee,   Date:
________________________________________   ____________________
Safety Director, or Designee,   Date:
________________________________________   ____________________
Safety Director, or Designee,   Date:
________________________________________   ____________________
Safety Director, or Designee,   Date:
________________________________________   ____________________
Safety Director, or Designee,   Date:
________________________________________   ____________________
Safety Director, or Designee,   Date:
________________________________________   ____________________
Safety Director, or Designee,   Date:


Date: October 15, 2001

To: PRINCIPIA College Employees

From: Paul Dixon, Director of Safety

Re: HBV Hepatitis B Vaccination Declination Form

Based on the nature of our business and our potential for exposure to blood and other potentially infectious materials (OPIM) from cuts, lacerations, etc., PRINCIPIA College has developed a Bloodborne Pathogens Program.

This program is available for review in my office, as well as the applicable OSHA regulations.

Under the standard, all potentially exposed employees, must be offered a HBV vaccination at no cost to the employee. Should you decline this vaccination, OSHA requires us to have you sign a HBV vaccination declination form. By signing this form, you in no way forfeit the opportunity to receive future vaccinations should a potential workplace exposure situation arise.

If you have any questions, please do not hesitate to contact me.

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.