Certain activities within the University of Maryland, Baltimore County
(UMBC) have the potential for exposure to human blood and/or body fluids. Human
blood, other body fluids, and unfixed human tissues are potential sources of
harmful and lethal diseases such as Hepatitis B and Acquired Immunodeficiency
Syndrome (AIDS). Therefore, to minimize the risk of occupational exposure to
potentially contaminated blood and body fluids, a combination of education,
personal protective equipment (PPE), vaccinations, engineering controls, and
application of recommended work practices will be used.
The following Bloodborne Pathogens Exposure Control Plan (ECP) has been
developed in accordance with the Occupational Safety and Health Administration
Pathogens Standard, 29 CFR 1910.1030 (reproduced as Appendix
C of this control plan), and the University of Maryland Baltimore County
(UMBC) Policy titled “UMBC Policy
Concerning Prevention and Management of Student and Employee Infection with
Bloodborne Pathogens” (May 2002)
|AIDS||Acquired Immunodeficiency Syndrome|
|ECP||Bloodborne Pathogens Exposure Control Plan|
|ESH||UMBC Environmental Safety & Health|
|HBV||Hepatitis B Virus|
|HCV||Hepatitis C Virus|
|HIV||Human Immunodeficiency Virus|
|OPIM||Other Potentially Infectious Material|
|OSHA||Occupational Safety & Health Administration|
|PPE||Personal Protective Equipment|
|SEH||Student and Employee Health Service|
|UMBC||University of Maryland, Baltimore County|
Bloodborne Pathogens means hepatitis B virus, human immunodeficiency virus,
and hepatitis C virus. In the future may identify additional pathogens as
bloodborne pathogens if such pathogens are identified by OSHA, the Centers for
Disease Control and Prevention (CDC), or a relevant State or federal law or
regulation as requiring control or prevention measures similar to those
required for HIV, HBV, or HCV under the OSHA Standard.
Exposure Incident means specific eye, mouth, other mucous membrane,
non-intact skin, or parenteral contact with blood or other potentially
infectious materials that result from the performance of the duties or
assignments of any UMBC personnel.
Needleless Systems are defined as devices that do not use needles for the
collection of bodily fluids or withdrawal of body fluids after initial venous
or arterial access is established, or the administration of medication or
fluids, or any other procedure involving the potential for occupational
exposure to bloodborne pathogens due to percutaneous injuries from contaminated
sharps. Examples of needleless systems include, but are not limited to, intravenous
medication delivery systems that administer medication or fluids through a
catheter port or connector site using a blunt cannula or other non-needle
connection, and jet injections that deliver injections through the skin without
use of a needle.
Occupational Exposure means reasonably anticipated skin, eye, mucous
membrane, or parenteral contact with blood or other potentially infectious
materials (OPIM) that may result from the performance of UMBC personnel’s
duties or assignments, including assigned work, volunteer tasks, academic
programs and practicum experiences. Occupational exposure may occur
in many contexts, including patient care, client services, research activities,
classroom work, and housekeeping, maintenance, and security services.
OSHA Standard means the Bloodborne Pathogens Standard issued by OSHA, United
States Department of Labor, as amended from time to time and published as 29
Other Medical Devices are defined as those devices designed to reduce the
risk of percutaneous exposure to bloodborne pathogens, including blunt suture
needles, plastic or mylar-wrapped glass capillary tubes, sharps disposal
containers, and biosafety cabinets.
Personal Protective Equipment (PPE) is specialized clothing or equipment
worn for protection against potentially infectious materials as well as the
spread of contamination of these materials.
Potentially Infectious Materials, as referenced by the OSHA Bloodborne
Pathogen Standard, are defined as the following human body fluids (in liquid or
dried state): blood, semen, vaginal secretions, cerebrospinal fluid, synovial
fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid,
saliva (in dental procedures only), any material visibly contaminated with
blood, any body fluid in a situation where it is difficult to differentiate
between types of body fluids; (ii) any unfixed tissue or organ (excluding skin)
from a human (living or dead); (iii) HIV-containing cell or tissue cultures,
organ cultures, and HIV or HBV-containing culture media or solutions; (iv)
blood, tissues, or cultures from animals experimentally infected with HIV, HBV,
HCV or other bloodborne pathogens.
Sharps with Engineered Sharps Injury Protections are defined as non-needle
sharps or needle devices used for withdrawing body fluids, accessing a vein or
artery, or administering medications or other fluids, with a built-in safety
feature or mechanism that effectively reduces the risk of an exposure incident.
They include, but are not limited to, syringes or catheters with a sliding
sheath over the needle or needles that retract.
Source Individual means any individual, living or dead, whose blood or other
potentially infectious materials may be a source of occupational exposure to
UMBC personnel. Examples include hospital and clinic patients, clients in
institutions for the developmentally disabled; trauma victims; clients of drug
and alcohol treatment facilities, residents of hospices and nursing homes,
human remains, and individuals who donate or sell blood or blood components.
UMBC Personnel means (i) all part-time and full-time students of UMBC as
well as any special students who are not registered; (ii) all employees of
UMBC, including full-time, part-time, temporary, contractual, and visiting
personnel in any employment category; and (iii) all volunteers participating in
Unit means any administrative, service, or research unit of UMBC which does
not report, directly or indirectly, to the Dean of a School.
Universal Precautions (Standard Precautions) are an approach to infection
control according to which all human blood and certain human body fluids are
treated as if known to be infectious for bloodborne pathogens. More
specifically, Universal Precautions means the universal precautions recommended
by the Centers for Disease Control and Prevention, U.S. Public Health Service.
More specifically, Standard Precautions means the standard precautions
recommended by the CDC.
Work Practice Controls refer to controls that reduce the likelihood of exposure
by altering the manner in which a task is performed.
Any term used in this Policy which is defined in paragraph (b) of the OSHA
Standard shall have the meaning set forth in the OSHA Standard unless a
different meaning is set forth in this part of the Policy.
III. EXPOSURE DETERMINATION
OSHA requires employers to perform an exposure determination concerning
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).
The exposure determination should identify job classifications in which all
employees may be expected to incur such occupational exposure, regardless of
frequency. In addition, OSHA requires a listing of job
classifications in which some employees may have occupational exposure. Since
not all the employees in these categories would be expected to have exposure to
blood and other body fluids that are to be considered potentially infectious
materials, the tasks, procedures or groups of closely related tasks and
procedures that would have occupational exposure for employees are required to
be listed by each School or Unit. Each School performs an exposure
determination for the School’s students.
IV. METHODS OF COMPLIANCE
OSHA requires that this plan include a schedule and method of implementation
for the various requirements of the standard.
The Centers for Disease Control and Prevention (CDC) Standard Precautions
will be observed at UMBC in order to prevent contact with blood or other
potentially infectious materials. All blood or OPIM will be considered
infectious regardless of the perceived status of the source individual.
Engineering and work practice controls will be utilized to eliminate or
minimize exposure to UMBC personnel. Where occupational exposure remains after
institution of these controls, personal protective equipment shall also be
utilized. The following engineering controls will be utilized:
Specimen Containers - Containers for specimens of blood or OPIM must be
designed to prevent leakage during collection, handling, and storage. They must
be inspected for leakage prior to use and on a daily basis. Contamination of
the outside of the container should be avoided. The lid shall be tightly
secured. The outside of the container shall be decontaminated before
transporting. All specimen containers must be clearly labeled as to contents,
labeled with a biohazard label, and then double containerized for transport.
Contact ESH at (410) 455-2918 for pick up and disposal procedures.
Containers for Special Medical Waste - Special medical waste such as used
disposable containers, gloves, etc., must be kept in closed containers that can
hold all contents without leakage during handling, storage, and transport.
Waste containers must be clearly labeled with the biohazard symbol, indicating
that they contain biohazardous waste. Containers are to be inspected for
leakage daily. Contact ESH at (410) 455-2918 for pick up and disposal
Sharps Containers - Sharps include syringes, needles, slides, scalpels,
cover slips, glass pipettes, and broken glass that may be contaminated with
infectious materials. Sharps containers are leak-proof, puncture-resistant,
labeled with the universal biohazard symbol, and closeable. Full sharps
containers must be placed in a properly lined biohazard burn box. Contact ESH
at (410) 455-2918 for pick up and disposal procedures.
Sharps with engineered sharps injury protection - Sharps that have a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident must be used whenever possible.
Labels - Warning labels must be affixed to containers of regulated waste, refrigerators, freezers, incubators, or other containers that contain blood or OPIM. They also must be placed on containers used to transport regulated materials, and are required for any equipment that can reasonably be expected to become contaminated during the course of its use.
warning label must contain the word “Biohazard” along with the universal
biohazard symbol and printed in fluorescent orange or orange-red color with
lettering or symbols in a contrasting color.
Signs - Signs will be posted at the entrance to work areas in which infectious and potentially infectious materials is used. Required signs will be fluorescent orange in a contrasting color and they must contain the following information:
The universal biohazard symbol;
The name of the infectious agent.
Special requirements for entering the area;
Name and daytime/nighttime telephone numbers of the laboratory supervisor
and/or other responsible person(s).
V. PERSONAL PROTECTIVE EQUIPMENT (PPE)
Personal protective equipment (PPE) is provided without cost to UMBC
personnel (for students, costs are included in the student fee). PPE is chosen
based on the anticipated exposure to blood or OPIM. Protective equipment will
be considered appropriate only if it does not permit blood or OPIM to pass
through or reach the individual’s 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.
Supervisors shall ensure that appropriate PPE in the appropriate sizes is
readily accessible at the work site or is issued without cost to UMBC
personnel. Hypoallergenic gloves, glove liners, powder free gloves, or other
similar alternatives shall be readily accessible to those who are allergic to
the gloves normally provided. PPE shall be removed before leaving the work site
and either be stored or disposed of appropriately.
The following pieces of PPE shall be available and used when there is
potential for exposure to bloodborne pathogens:
Gloves - Disposable, long-sleeved (11-inch), single-use latex or nitrile
gloves shall be worn where it is reasonably anticipated that UMBC Personnelwill have hand contact with blood or
other potentially infectious materials, when collecting and processing human
specimens, and when handling or touching contaminated items or surfaces.
Disposable gloves are not to be washed or decontaminated for reuse and are
to be replaced as soon as practical when they become contaminated, or as soon
as feasible if they are torn or punctured, or when their ability to function as
a barrier is compromised. Utility gloves can be washed or decontaminated for
reuse. Utility gloves 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. Double gloving has been shown to provide
more protection from punctures and abrasions that can occur during use than
does a single glove layer. Gloves shall be checked for leaks prior to wearing
them. If gloves are damaged (torn or punctured) or become damaged or
contaminated during a procedure, they shall be replaced. Hands must be washed
with soap and water for 30 to 60 seconds immediately after gloves are removed.
Clothing - Protective clothing must be worn when there is a risk of body
fluids spattering or becoming aerosolized and contacting an individual’s skin
or clothing. Protective clothing should be resistant to fluids, and may be
disposable or reusable. Reusable clothing must be properly laundered prior to
Face Protection - Face shields or masks in combination with eye protection
such as goggles or glasses with solid side shield are required to be worn when
splashes, sprays, aerosolized blood, or other potentially infectious materials
may contact eyes, nose, mouth, or mucous membranes.
Eyewear - Safety glasses with side shields or face shields must be worn
during all work with potentially infectious material whenever there is a
potential for splashes or sprays.
Protective Footwear and Headwear - Disposable shoe covers and caps must be
worn in situations where cross contamination of materials or personnel is
Supervisors shall ensure that all PPE is removed when penetrated by blood
and then double bagged for laundering. All PPE shall be removed prior to
leaving the work area. When PPE is removed, it shall be placed in an
appropriately designated container for storage, washing, decontamination, or
disposal. All repairs and replacements will be made by UMBC at no cost to UMBC
VI. WORK PRACTICE CONTROLS
Work practice controls are procedures that reduce the risk of occupational exposure by altering the way a task is performed. The following work practice controls are to be followed by all UMBC personnel when working with human blood or OPIM.
Hand Washing - After the removal of personal protective gloves, UMBC
personnel shall wash hands and any other potentially contaminated skin area
immediately or as soon as feasible with soap and running tap water for at least
ten seconds. If UMBC personnel incur exposure to their skin or mucous
membranes, then those areas shall be washed or flushed with running tap water
for at least 10 minutes as soon as feasible following contact.
Needles and Sharps - Contaminated needles and other contaminated sharps
shall 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, no alternative is feasible, and the action is
required by the medical procedure. If such action is required, the recapping or
removal of the needle must be done by the use of a mechanical device or a
one-handed technique. Procedures which require recapping of needles are
Personal Hygiene - Applying cosmetics and handling contact lenses in the
laboratory are forbidden at all times. Hands shall be washed with soap and
water before leaving the work site.
Food and Drink - Food and drink are never to be stored or consumed in a
Handling of Materials - Packages marked with the universal biohazard symbol
or otherwise identified as containing potentially infectious materials are to
be inspected for leaks immediately upon arrival.
All procedures are to be conducted in a manner which will minimize
splashing, spraying, splattering, and generation of droplets of blood or OPIM.
Specific methods include the use of protective clothing, gloves, chin length
face shields, eye protection, and the use of utility gloves to protect
latex/nitrile gloves from abrasion and tearing when large items are handled.
Sharp objects must be handled with safety awareness. Eye contact must be
maintained with the item. Machines that splash and splatter shall be shielded.
Capped tubes and safety cups shall be used when vortexing and centrifuging.
Cotton or a gauze pad moistened with disinfectant shall be wrapped around
rubber stoppers or lyophilized containers when opening them. To the extent possible,
all procedures that could aerosolize material shall be performed in a Biosafety
Specimens of blood or OPIM are to be placed in a container that prevents
leakage during the collection, handling, processing, storage, and transport of
the specimens. The container used for this purpose shall be labeled in
accordance with the requirements of the OSHA standard. Supervisors shall ensure
that all equipment has been decontaminated prior to servicing and shipping.
Any specimen container(s) shall be placed within a secondary container that
is leak-proof and closed to prevent spillage of infectious materials.
Specimen Collection - When specimens are collected, the liquid must never be
forced into a tube or other container.
Routine Cleaning - All areas of the worksite must be maintained in a clean
and sanitary condition. All tables must be disinfected with an appropriate
disinfectant solution at least daily and immediately following completion of
procedures involving human blood and OPIM.
Contaminated Work Surfaces – Contaminated work surfaces must be
decontaminated with an appropriate disinfectant solution after completion of
procedures involving and/or immediately following any spill of blood or OPIM.
Recommended liquid disinfectant contact time for effective decontamination is
Broken Glass – Broken glass must never be picked up by hand. Recommended
mechanical means of cleanup include use of a brush and dust pan, stiff paper,
tongs, or forceps. Utensils must be cleaned and decontaminated immediately
after use. The contaminated glass should be discarded into a sharps container.
Contaminated Sharps – Contaminated sharps must be placed in a properly
marked sharps container and labeled with a biohazard symbol. Containers for
contaminated sharps shall be easily accessible to UMBC personnel and located in
each separate work or procedure area. The container shall be maintained upright
throughout its use and replaced as needed and shall not be overfilled. When a
container of contaminated sharps is moved from the area of use, the container
shall be closed immediately prior to removal. The sharps container shall be
placed in a plastic-bag-lined biohazard burn box.
Laundry - Contaminated protective clothing is to be placed in labeled bags
and sent to a commercial laundry service which has the capability to properly
handle and launder potentially infectious material. Home laundering is not
The above controls will be examined and maintained on a regular schedule.
The effectiveness of the controls will be reviewed annually and updated as
To achieve the goals of this policy, supervisors and managers are required
to develop Standard Operating Procedures (SOPs) for activities in which UMBC personnel
may be exposed to bloodborne pathogens.
The procedures must contain the following elements:
A clear and descriptive position description (title);
The names and classifications of all individuals who will participate in the
bloodborne pathogen activities;
Identification of the area where duties are performed and a description of
the procedures to be used to prevent unauthorized persons from being exposed to
a potential hazard;
A listing of the possible sources of exposure to bloodborne pathogens or
other potentially infectious material in the specific task or procedure (Note:
All liquids or media that come into contact with blood, unfixed human tissue,
or human cell lines are to be considered potentially infectious material until
the source tissue has been disinfected.);
A detailed description of the task or procedure including all of the
applicable safety precautions detailed in the Bloodborne Pathogens Exposure
Control Plan (ECP);
Identification of the departmental point of contact for exposure incidents.
VIII. HEPATITIS B VACCINATION PROGRAM
UMBC offers the hepatitis B vaccination series to UMBC employees who have
occupational exposure. Hepatitis B vaccination shall be available to UMBC
employees 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
health care professional, and provided according to the recommendations of the
U.S. Public Health Service.
The hepatitis B vaccination shall be offered by UMBC, at no cost, to all
employees who have potential occupational exposure. Students who have potential
occupational exposure will be offered the hepatitis B vaccination on campus at
the student’s expense.
Any persons who are neither students nor employees, and who have occupational exposure, shall be offered the hepatitis B vaccination at their own expense.
Participation in a pre-screening program shall not be a prerequisite for receiving hepatitis B vaccination. If an individual initially declines hepatitis B vaccination but at a later date, while still covered under the standard, decides to accept the vaccination, the vaccination shall then be made available. Employees and students at risk of exposure who decline the hepatitis B vaccination offered shall sign the OSHA waiver indicating their refusal (see forms in Appendix B). All UMBC personnel may be vaccinated at University Health Services.
If a routine booster dose of hepatitis B vaccine is recommended by the U.S.
Public Health Service at a future date, such booster shall be made available.
IX. BLOODBORNE PATHOGEN POST-EXPOSURE EVALUATION AND FOLLOW-UP
Individuals exposed to a bloodborne pathogen shall first wash the exposed
site with soap and water and then contact the Needlestick Hotline at 410-328-2337,
extension STIK (7845). The Needlestick Hotline is available 24 hours per day, 7
days per week including holidays. If appropriate, the individual will be
referred to University Health Services if the call is made during regular
business hours, or to Concentra Medical Center if the call is made after
business hours. See Table 1 for a detailed list of responsibilities for each
unit. Current CDC guidelines call for medical treatment of high risk exposures
to be initiated .
All employeeexposure incidents shall be reported,
investigated, and documented. If an employeeincurs
an exposure incident, the employee shall report the incident to his or her
supervisor. If a student incurs an exposure, the student shall be encouraged to
report the incident to the University Health Center. Employees with potential exposure shall
follow the medical advice given them by the healthcare professional staffing
the Needlestick Hotline.
Follow-up care willbe available at UMBC University Health Services. During the School Year, UHS hours are: Monday-Thursday 8:00am-7:30pm, Friday 8:00am-5:00pm. During Winter Session and Summer Session: Monday-Friday 8:00am-4:30pm.
Following a report of an exposure incident, an exposed employee shall
receive a confidential medical evaluation and follow-up, including at least the
Documentation of the route of exposure and the circumstances under which the
exposure incident occurred;
Identification and documentation of the source individual, unless it can be
established that identification is infeasible or prohibited by state or local
The source individual’s blood shall be tested as soon as feasible after
consent is obtained in order to determine HBV, HCV, and HIV infectivity. If
consent is not obtained, the person responsible for the hepatitis B vaccination
program shall establish that legally required consent cannot be obtained. If
the source individual’s consent is not required by law, the source individual’s
blood, if available, shall be tested and the results documented;
Results of the source individual’s testing shall be made available to the
exposed employee along with information on applicable laws and regulations
concerning disclosure of the identity and infectious status of the source
Collection and testing of blood for HBV, HCV, and HIV serological status
will comply with the following:
The exposed individual’s blood shall be collected as soon as feasible and
tested after consent is obtained;
The exposed individual shall be offered the option of having his or her
blood collected for testing of HIV/HBV/HCV serological status. The blood sample
shall be preserved for up to 90 days to allow the individual to decide if the
blood should be tested for HIV serological status.
Employees who experience an exposure incident shall be offered post-exposure
evaluation and follow-up in accordance with the OSHA standard.
The health care professional responsible for the person’s hepatitis B
vaccination and post-exposure evaluation shall be provided with the following:
A copy of 29 CFR 1910.1030 (Appendix C);
A written description of the exposed individual’s duties as they relate to
the exposure incident;
Written documentation of the route of exposure and circumstances under which
Results of the source individual’s blood testing, if available;
All medical records relevant to the appropriate treatment of the person
including vaccination status.
UMBC shall obtain and provide to an exposed employee a copy of the evaluating
health care professional’s written opinion within 15 days of the completion of
The health care professional’s written opinion for hepatitis B vaccination must be limited to whether it is indicated, and whether the employee has received such vaccination. It shall include a statement that the employee has been informed of the results of the evaluation and of any medical conditions resulting from exposure to blood or OPIM which require further evaluation or treatment. All other findings or diagnosis shall remain confidential and shall not be included in the written report.
X. INFORMATION AND TRAINING
The annual review and update of the exposure control plan is required to:
Reflect changes in technology that eliminate or reduce exposure to
Document annually consideration and implementation of appropriate
commercially available and effective safer medical devices designed to
eliminate or minimize occupational exposure. Documentation should
include a description of the safer devices identified as candidates for
adoption, the methods used to evaluate devices, the results of evaluations, and
the justification for selection decisions.
Selection and evaluation of devices by Schools or units should be based on
the following factors:
The device's ability to perform the function for which it was designed;
The effect of the engineered sharps injury protection on patient care;
Expected effectiveness in reducing injuries;
Ease of use;
Compatibility with other devices and systems;
Solicitation of employee input during selection of safe sharps:
Regulations require that input be solicited from some non-managerial
employees responsible for direct patient care who are potentially exposed to
injuries from contaminated sharps. Such input may be solicited through periodic
conversations, informal problem-solving groups, and participation in safety
audits, worksite inspections, exposure incident investigations, or evaluation
through pilot testing.
The Office of Environmental Safety & Health can assist Schools or units
with examples of safe sharps evaluation forms obtained from OSHA Instruction
Directive CPL 2-2.69, Enforcement Procedures for the Occupational Exposure to
Bloodborne Pathogens, effective date November 29, 2001. This publication is
also available at http://www.osha-slc.gov/OshDoc/Directive_pdf/CPL_2-2_69.pdf
Solicitations will identify the employees involved, the process by which
input was requested, and the input obtained using meeting minutes. Copies of
documents used to request participation and records of responses received will
be incorporated into the Exposure Control Plan.
Employees solicited may include lab technicians, housekeeping staff,
maintenance workers, and management-level personnel who may be at risk of
injury involving contaminated sharps.
Training shall be required for all UMBC personnel who may have exposure to
bloodborne pathogens in the course of their employment, studies, or volunteer
effort. UMBC shall ensure that bloodborne pathogens trainers are knowledgeable
in the subject matter. UMBC shall ensure that training is provided at the time
of initial assignment to tasks where occupational exposure may occur and that
training shall be repeated every twelve months.
Training shall be tailored to the education and language level of UMBC
personnel being trained and provided at no cost and during the normal work
shift ornormal class hours. The training will
be interactive and cover the following:
Bloodborne Pathogen Standards and
contents of the regulations;
The epidemiology and symptoms of bloodborne diseases;
The modes of transmission of bloodborne pathogens;
The Exposure Control Plan 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 PPE;
The types, use, location, removal, handling, decontamination, and disposal
The basis of selection of PPE;
The hepatitis B vaccine, including efficacy, safety, method of
benefits, and cost, if any;
The appropriate actions to take and persons to contact in an emergency
involving blood or OPIM;
The procedure to follow if an exposure incident occurs, including the method
of reporting and medical follow-up;
The evaluation and follow-up required after an exposure incident;
The signs, labels, and color coding systems used to identify potentially
Additional training shall be provided to UMBC personnel when there are any
changes of tasks or procedures affecting the personnel’s occupational exposure.
XI. RECORD KEEPING
The UMBC Office of Environmental Safety & Health (ESH) is responsible
for maintaining employee training records. 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, social security numbers, and titles of all persons attending
the training sessions.
The University Health Service is responsible for maintaining employeemedical records as indicated below.
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, studies, or volunteer effort plus 30 years.
The records shall include the following:
The name and social security number of the individual;
A copy of the individual’s HBV vaccination status, including the dates of
A copy of all results of examinations, medical testing, and follow-up
A copy of the information provided to the health care professional,
including a description of the individual’s duties as they relate to the
exposure incident, and documentation of the routes of exposure and
circumstances of the exposure.
ESH shall maintain a sharps injury log for recording percutaneous injuries
from contaminated sharps. The information in the log shall be recorded
and maintained in a manner that will protect the confidentiality of exposed
UMBC personnel to the extent permitted by law. The log will serve as a tool for
ESH to identify high risk areas and devices. It shall contain at least:
The type and brand of device involved in the incident;
The department or work area where the exposure incident occurred;
An explanation of how the incident occurred and the circumstances
surrounding the exposure incident (procedure being performed, the body part
affected, objects or substances involved, and how they were involved);
The log can be maintained as a paper file or electronically, so long as
privacy is protected.
The OSHA 300 Log of Work-Related Injuries and Illnesses and the OSHA 301
Injury and Illness Incident Report forms shall be used to meet the sharps
injury log requirements, provided that:
The forms contain information on the type and brand of the device involved;
Reports of sharps injuries can be segregated from other types of work-related
injuries and illnesses.
Employee medical records in the possession of UMBC shall be made available
to the employee in accordance with 29 CFR 1910. 20. Medical 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 (NIOSH) upon request.
Transfer of Records
If UMBC has closed and there is no successor employer to receive and retain
the medical records for the prescribed period, the Director of NIOSH shall be
contacted for final disposition.
Evaluation and Review
This program and its effectiveness will be reviewed every year by ESH and
updated as needed.
UMBC Employee or Student
Wash the affected site with soap and water.
Call the Needlestick Hotline 410-328-2337 and enter STIK (7845)
Report all incidents, exposures and potential exposures. Report all conditions that may endanger the health of staff, students and patients
Department Manager, Principal Investigator, Laboratory Supervisor, or Shift Supervisor
Determine the circumstances of an exposure to a bloodborne pathogen and assist with completion of an Employee’s First Report of Injury form (Appendix A)
Direct employee/student exposed to bloodborne pathogens to the University Health Services for confidential evaluation
University Health Services
Manage HBV employee vaccinations. Offer hepatitis B vaccination to all employees included in the UMBC Bloodborne Pathogen Exposure Program
Determine treatment guidelines, medical oversight, and coordination of all activities related to medical management of employees/students who have sustained an exposure to bloodborne pathogens
Conduct follow-up internal testing, and maintain documentation as required
Environmental Safety & Health (ESH)
Oversee the coordination of management resources to address both individual and institutional concerns in regard to health and safety issues pertaining to bloodborne pathogens
Maintain all training documentation regarding bloodborne pathogens
Review, evaluate, and assist in the selection of proper personal protective equipment
Participate in the resolution of health and safety issues in the workplace
Coordinate the provision of required training and retraining with the designated administrator in the School or unit.
Develop, coordinate, and disseminate educational programs for staff and students
Train and/or retrain all appropriate employees/students as needed
Monitor work practices to determine the need for training/retraining and to ensure compliance with policy.
Schedule and document training process; coordinate education programs.
Evaluate all incidents involving potential exposure to bloodborne pathogens by staff and students
Block SS, ed. Disinfection, Sterilization, and Preservation. 5th ed. 2001. Lippincott Williams & WilkinsFebiger, Philadelphia, PA.
Bloodborne Pathogens Standard (CFR 1910.1030) U.S. Occupational Safety and
Health Administration, December 1991. 29 CFR Part 1910. OSHA Needlesticks &
Other Sharps Injuries; Final Rule, January 2001.
Garner, J and the Hospital Infection Control Advisory Committee. Guideline
for Isolation Precautions in Hospitals. Infection Control and Hospital
Epidemiology, 1996, pages 53-80.
Hospital Infection Control Practices Advisory Committee. Guideline for
prevention of nosocomial pneumonia. Parts I and II. Am J Infect Control
Martin, MA, Reichelderfer, M. APIC guideline for infection prevention and
control in flexible endoscopy. Am J Infect Control 1994;22:19-38.
Protection Against Viral Hepatitis. Recommendations of the Immunization Practices
Advisory Committee (ACIP). CDC Publication: MMWR, February 9, 1990, No. RR-2.
Public Health Service Guidelines for the Management of Health-Care Worker
Exposures to HIV and Recommendations for Postexposure Prophylaxis. CDC
Publication: MMWR, May 15, 1998, Vol. 47, No. RR-7.
Rutala WA. Guideline for selection and use of disinfectants. Am J Infect
Control 1996;24: 313-342.
EMPLOYEEHEPATITIS B VACCINE DECLINATION
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
vaccine 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.
Employee Name: ___________________________________
Employee Signature: ________________________________
Social Security Number: _______________
Witness Signature: _________________________________
Witness Name: ____________________________________
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. 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 my