Policy No.     AD-1373.6





   EFFECTIVE DATE:   November 25, 2002*

       (*Title Updates 5/7/05)


         CANCELLATION:   none

      OFFICE:   Administrative Affairs (AD)

















Delgado Community College is committed to providing a safe and healthy work environment for our entire staff. In pursuit of this endeavor, the following Exposure Control Plan (ECP) has been developed in accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030. The purpose of this ECP includes elimination or minimization of employee occupational exposure to blood or certain other body fluids, compliance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030, and the protection of Delgado Community College's students, faculty, staff, and visitors.


   This memorandum, also described as the College’s Exposure Control Program  (ECP) is a key document to assist the College in implementing and ensuring compliance  with the standard, thereby protecting College employees.






1 .  Purpose


To establish procedures for dealing with potential exposure to blood borne pathogens at Delgado Community College.



2.   Scope and Applicability


This policy and procedures memorandum applies to all College operating units and to all employees, students and visitors of Delgado Community College.




3.   Program Administration


 The Health Services EMT-Paramedic is responsible for the implementation of the  Exposure Control Plan (ECP). This individual will maintain, review and update the  ECP at least annually and whenever necessary to recommend new or modified tasks and  procedures.


 Those employees who have occupational exposure to blood or other potentially  infectious materials (OPIM) must comply with the procedures and work practices  outlined in  this memorandum.


 The College Health Services EMT-Paramedic will maintain and provide all  necessary personal protective equipment (PPE), engineering controls (i.e., sharps containers),  labels, and red bags as required by the standard. He/she will also ensure that adequate  supplies of the aforementioned equipment are available in the appropriate sizes.


 The College Health Services EMT-Paramedic in conjunction with the Human    Resources Department will be responsible for ensuring that all medical actions required are  performed and that appropriate employee health records are maintained.


   The College Health Services EMT-Paramedic will be responsible for training,  documentation of training, and making the written ECP available to employees.


 The Maintenance Department will be responsible for the proper disposal of all  medical waste produced by actions occurring on any campus in the pursuit of the proper  application of the Bloodborne Pathogen Program.



4.   Employee Exposure Determination


   The U.S. Occupational Safety Health Administration (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 (i.e., employees are  considered to be exposed even if they wear personal protective equipment).


   The exposure determination of Ongoing Exposure Risk   includes all job  classifications in which employees will incur such occupational exposure, regardless of  frequency. At the College the following job classifications are in this category:


  l   College Health Services EMT-Paramedic


  l   College personnel assisting with administering vaccinations


  l   Nursing/Allied Heath Faculty with exposure to clinical settings


  l   Any College personnel assisting with providing health services, clerical and      administrative staff working with the above mentioned classifications



5.   Implementation of Methods of Exposure Control


   This plan includes a schedule and method of implementation for the various  requirements of the standard. It is the College's policy to comply with this  requirement.  Employees covered by the bloodborne pathogen standard receive an explanation of this  ECP during their initial training session. It will also be reviewed in their annual refresher  training. All employees have an opportunity to review this plan at  any time during their  work shift by contacting the custodian of the Delgado Community College Loss Prevention  Manual in their departmental office. If requested, the College Health Services EMT-  Paramedic will provide an employee with a copy of the ECP.



6.   Compliance Strategies


 A.  The Centers for Disease Control (CDC) Universal Precautions: will be        observed at the College 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.


 B.   Engineering and Work Practice Controls: will be utilized to eliminate or      minimize exposure to employees at the College. Where occupational exposure      remains after the institution of these controls, personal protective equipment shall      also be utilized. At the College the following engineering controls will be        utilized:


   1.  Hand-Washing Facilities


     Hand washing facilities are available to the employees who incur exposure      to blood or other potentially infectious materials.


     OSHA requires that these facilities be readily accessible after incurring        exposure. In College lavatories employees should not have to open doors        or use stairs to access washing facilities in order to avoid further surface        contamination.


     Supervisors shall ensure that after the 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.


     Supervisors shall ensure that if employees incur exposure to their skin or

     mucous membranes, then those areas shall be washed or flushed with        water as soon as feasible following contact.


   2.   Sharps, Contaminated Needles & Glassware


     Contaminated needles and other contaminated sharps will not be bent,

     recapped, removed, sheared or purposely broken. OSHA allows an        exception to this if the procedure would require that the contaminated        needle be recapped or removed and no alternative is feasible and the action      is required by the medical procedure. If such action is required, then the        recapping or removal of the needle must be done by the use of a          mechanical device or a one-handed technique.


   3.  Disposal of Sharps, Contaminated Needles & Glassware


     All sharps must be placed in a labeled, biohazard sharps container. All

     needles are to be placed in a labeled biohazard needles/sharps container.


     Contaminated sharps shall be discarded immediately or as soon as feasible

     in containers that are closable, puncture resistant, leak proof on sides and        bottom and labeled or color coded. Delgado Community College will        provide leak-proof containers for contaminated sharps capable of resisting        punctures and labeled as a biohazard. These containers are to be used for        gathering and storage of all contaminated sharps, including glassware.


      l   During use, containers for contaminated sharps shall be easily          accessible to personnel and located as close as is feasible to the

       immediate area where sharps are used or can be reasonably            anticipated to be found (i.e., Exam rooms, Laboratory, Nursing

       triage area, Training room).


      l   Employees are to use unwinders to separate needles from syringes

       and vacutainers and are to be trained regarding proper removal of



      l   The containers shall be maintained upright throughout use,

       replaced routinely and not be allowed to overfill. They are to be

       checked every  time there is a pickup of infectious waste and

       changed when they are nearly full.



      l   When moving containers of contaminated sharps from the area of

       use, the containers shall be closed immediately prior to removal or

       replacement to prevent spillage or protrusion of contents during

       handling, storage, transport, or shipping.


      l   The container shall be placed in a secondary container if leakage of

       the primary container is possible. The second container shall be

       closeable, constructed to contain all contents and prevent leakage

       during handling, storage and transport, or shipping. The second

       container shall be labeled or color-coded to identify its contents.


 4.  Other Regulated Waste


     Delgado Community College will provide containers sufficient to contain        regulated wastes capable of resisting punctures and labeled as a biohazard

     (as appropriate). Regulated Waste includes the following:


      l   Liquid or semi-liquid blood or other potentially infectious material.


      l   Items contaminated with blood or other potentially infectious

       material that would release these substances in a liquid or semi

       liquid if compressed.


      l   Items that are caked with blood or other potentially infectious

       material and are capable of releasing these substances during



      l   Pathologic and microbiological waste containing blood or other

       potentially infectious material.


     Other regulated waste shall be placed in containers, which are closeable, c        constructed to contain all contents and prevent leakage of fluids during

     handling, storage, transportation or shipping. The waste must be 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 shall be in accordance with applicable        Federal, State and Local regulations.


 C.  Personal Protective Equipment (PPE): PPE must be used to prevent blood or      Other Potentially Infectious Materials (OPIMs) from passing through to, or      contacting the employee’s work or street clothes, undergarments, skin, eyes,

   mouth, or other mucus membranes, unless engineering controls and work

   practices have eliminated occupational exposure. An employee may temporarily

   decline to wear PPE only when, in a life-threatening situation, the use of

   protective equipment will prevent the delivery of health care and public safety

   services or pose an increased hazard to workers. Incidents during which an

   employee elects not to wear protective equipment are to be documented in order

   to determine whether changes can be instituted to prevent occurrences in the



   Delgado Community College assumes the financial responsibility for purchasing      PPE that protects its employees against contact with blood or OPIM as can be      reasonably anticipated encountering in its setting. If laboratory coats and

   uniforms are to be used as PPE, they will be laundered through Contract hire on a

   as needed basis, and are not to be taken home for cleaning. The College Health      Services EMT-Paramedic will provide the PPE required by bloodborne first      responders teams, in order to protect them in the execution of their duties.


   All PPE must be removed prior to leaving the work area, removed as soon as      possible following penetration by blood or OPIM and placed in a designated area

   or container for storage, washing, decontamination or disposal.


 D.  Housekeeping Practices


   1.  Regulated Waste


     Regulated waste is to be placed in containers, which are closable,          constructed to contain all contents and prevent leakage, appropriately        labeled and color coded, and closed prior to removal, to prevent spillage or      protrusion of contents during handling.


   2.  Work Surfaces 


     Work surfaces are to be decontaminated with a detergent or 10% bleach        solution after completion of procedures, immediately upon contamination        by any spill of blood or OPIM and at the end of each work shift.


   3.  Protective Coverings


     Non-absorbent, protective coverings, are to be used to cover equipment        and surfaces when they have become overtly contaminated and at the end        of a work shift if they have become contaminated.


   4.  Reusable Receptacles


     Reusable receptacles like bins, garbage receptacles, and pails will be

     decontaminated weekly. When contamination is visible, receptacles

     should be decontaminated immediately.


   5. Broken Glassware


     Broken glassware, which may be contaminated, must not be picked up        directly with the hands. Tools used in cleanup of broken glass are to be        decontaminated and broken glass discarded in a sharps container. Do not        use vacuum cleaner for cleanup of contaminated glass.


   6. Laundry


     Laundry contaminated with blood or other potentially infectious materials        will be handled as little as possible. Such laundry will be placed in          appropriately marked "A biohazard", labeled, or color-coded red bags at        the location where it was used. Such laundry will not be sorted or rinsed in      the area of use.


  E.  Labeling Procedures of Blood or OPIM


   Labels to be used to warn employees who may have contact with containers, of      the potential hazard posed by their contents. Labels are to be attached to container    of regulated waste, to refrigerators containing blood and OPIM, and to other      containers used to store, transport, or ship blood or OPIM. The warning label      must be fluorescent orange or orange red, containing the biohazard symbol and      the word “biohazard” in a contrasting color and be attached to prevent loss or      unintentional removal of the label.


 F.  General Practices


    l   Food and Drinks are not to be kept in refrigerators, freezers, shelves,

     cabinets, or on countertops where blood or OPIMs are present.


    l   Applying cosmetics or contact lenses is prohibited in areas where blood or

     OPIMs are present.


    l   All procedures involving blood or OPIMs must be performed in such a

     manner as to minimize splashing, spraying, splattering and generation of

     droplets of these substances.


 G.  Hepatitis B Vaccine


   The College Health Services EMT-Paramedic will provide training to employees      on Hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of      administration, and availability. The Hepatitis B vaccination series is available at      no cost after training and within (ten) 10 days of initial assignment to employees      identified in the exposure determination section of this plan.


   Vaccination is encouraged unless:


    l   Documentation exists that the employee has previously received the series.


    l   Antibody testing reveals that the employee is immune.


    l   Medical evaluation shows that vaccination is contraindicated.


   However, if an employee chooses to decline vaccination, the employee must sign

   a declination form. This declination form will be kept with the employee’s

   medical file in the College Health Services EMT-Paramedic’s office. Employees      who declined the vaccine may request and obtain the vaccination at a later date at      no cost. The College Health Services EMT-Paramedic will provide the required      vaccinations in their office. Following Hepatitis B vaccinations, the health care      professional will provide a Written Opinion, which will be limited to whether the      employee required the hepatitis vaccine, and whether the vaccine was        administered. This Written Opinion will also be kept in the employee’s medical      file in the College Health Services EMT-Paramedic’s office.


 If the U.S. Public Health Service recommends a routine booster dose of the      Hepatitis B vaccine at a future date, such booster doses shall be made available at      no cost to the employee.



7. Information and Training


 All employees who have occupational exposure to bloodborne pathogens must receive

 training on the epidemiology, symptoms, protection from, and transmission of bloodborne

 pathogen diseases. The College Health Services EMT-Paramedic will provide this training.  This training will be provided at no cost to the employee and during the employees’ working  hours. The training will be as follows:


A.  Will be provided by the College Health Services EMT-Paramedic. He/she      shall ensure that training is provided at the time of initial assignment to tasks      where occupational exposure may occur, and that it shall be repeated within       twelve (12) months of the previous training.


 B.  Training shall be 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:


    l   A copy of the standard and an explanation of its contents.


    l   A discussion of the epidemiology and symptoms of bloodborne diseases.


    l   An explanation of the modes of transmission of bloodborne pathogens.


    l   An explanation of the Delgado Community College Bloodborne Pathogen        ECP, and a method for obtaining a copy.


    l   The recognition of tasks that may involve exposure.


    l   An explanation of the use and limitations of methods to reduce exposure;        for example, engineering controls, work practices and personal protective        equipment (PPE).


    l   Information on the types, selection, use, location, removal, handling,        decontamination, and disposal of PPEs.


    l   Information on the Hepatitis B vaccination, including efficacy, safety,        method of administration, benefits, and that it will be offered free of        charge.


    l   Information on the appropriate actions to take and persons to contact in an        emergency involving blood or other potentially infectious materials.


    l   An explanation of the procedures to follow if an exposure incident occurs,        including the method of reporting and medical follow up.


    l   Information on the evaluation and follow up required after an employee

     exposure incident.


    l   An explanation of the signs, labels, and color-coding systems.


 C.  Employees who have received training on bloodborne pathogens in the 12 months    preceding the effective date of this plan shall only receive training in provisions of    the plan that were not covered.


 D.  Additional training shall be provided to employees when there are any changes of      tasks or procedures affecting the employee's occupational exposure.



8.   Recordkeeping


 A.  Medical Records are maintained for each employee with occupational exposure in    accordance with 29 CFR 1910.20, "Access to Employee Exposure and Medical      Records."


   The College Health Services EMT-Paramedic is responsible for maintenance of the    required medical records. These confidential records are kept in these said offices for    at least the duration of employment plus 30 years. Employee medical records are      provided upon request of the employee or to anyone having written consent of the      employee within 15 working days. These medical records include:


    l   Name and Social Security Number of the employee.


    l   Employee Hepatitis B vaccination status including dates of vaccination        and the records relating to the employee’s ability to receive the vaccine        and signed declination form, if applicable.


    l   A copy of all the results of examinations, medical testing, and follow-up        procedures.


 B.  Training records are completed for each employee upon completion of training.      These documents will be kept for at least three years at the College Health        Services EMT-Paramedic and the Senior Compliance Officer. The training records    include:


    l   The dates of the training sessions.


    l   The contents or a summary of the training sessions.


    l   The names and qualifications of persons conducting the training.


    l   The names and job titles of all persons attending the training sessions.


 C.  The College Health Services EMT-Paramedic will maintain a log of occupational      injury or illness. Identifying information related to bloodborne pathogens will be      removed prior to granting access to the records. The log will document the      following:


    l   Date of incident.


    l   Name and Social Security number of the exposed individual.


    l   Hepatitis B vaccination status.


    l   Medical follow up, examination results, and medical testing.


    l   Confidential medical information must be retained while the employee is        employed by Delgado Community College and for thirty (30) years        thereafter.


   Employee medical records will be provided upon request, for examination and      copying to the employee, the Director of NIOSH, the Assistant Secretary of      Occupational Safety and Health, and to anyone having the written consent of the      employee.




10.   Post- Exposure Evaluation and Follow-Up


 Should an exposure incident occur, employees must contact the College Health Services  EMT-Paramedic who will conduct an immediately available confidential medical evaluation  and follow-up. Following the initial first aid (clean the wound, flush eyes or other mucous  membrane, etc.), the following activities will be performed:


  l   Document the routes of exposure and how the exposure occurred.


  l   Identify and document the source individual (unless the employer can establish      that identification is infeasible or prohibited by state or local law).

  l   Obtain consent and make arrangements to have the source individual tested as      soon as possible to determine Human Immune Deficiency Virus (HIV), Hepatitis      C Virus (HCV) and/or Hepatitis B Virus (HBV) infectivity. Document that the      source individual's test results were conveyed to the employee's health care      provider.


  l   If the source individual is already known to be HIV, HCV and/or HBV positive,      new testing need not be performed.


  l   Assure that the exposed employee is provided with the source individual's test      results and with information about applicable disclosure laws and regulations      concerning the identity and infectious status of the source individual (e.g., laws      protecting confidentiality).


  l   After obtaining consent, collect exposed employee's blood as soon as feasible      after exposure incident, and test blood for HBV and HIV serological status.


  l   If the employee does not give consent for HIV serological testing during        collection of blood for baseline testing, preserve the baseline blood sample for at      least ninety (90) days; if the exposed employee elects to have the baseline sample      tested during this waiting period, perform testing as soon as feasible.






J. Terence Kelly





Policy Reference:

   Occupational Safety Health Administration (OSHA) Standard: Bloodborne Pathogens,        29 CFR 1910.1030

 Occupational Safety Health Administration (OSHA) Standard: Access to Employee      Exposure and Medical Records, 29 CFR 1910.20


Review Process:

  Safety Committee 3/14/02

  Bloodborne Pathogen Policy Ad Hoc Review Committee 11/22/02:

Executive Committee 11/25/02




Distributed Electronically Via the College’s Internet and Email Systems



Back to top