Policy 3109
Bloodborne Pathogens UNDER REVIEW

Date of Current Revision: May 2002
Primary Responsible Officer: University Health Center



This policy advises classified employees, faculty members, administrators, student employees and all other employees of the university of the practices and procedures to help prevent exposure to the Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV) by blood and other body fluids.


This program is mandated for all at risk employers/employees by the United States Department of Labor in Occupational Safety and Health Act (OSHA) Standard 29 CFR 1910.1030 of March 6, 1992, and by the Commonwealth of Virginia through Virginia Occupational Safety and Health (VOSH) and is applicable to the university.

The President of the university has given the Vice President for Student Affairs the responsibility and the authority to ensure that these guidelines are followed and complied with.


At risk employees:
All employees who could be "reasonably anticipated," as a result of performing their job duties, to have contact with blood and other potentially infectious materials.

Exposure incident:
A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.

Other body fluids:
Substances such as human semen, vaginal secretions, cerebrospinal fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any fluid visibly contaminated with blood, and indistinguishable body fluids.


This policy applies to all employees of the university.


Members of the university community are to comply with OSHA and VOSH health related codes, laws and standards applicable to the handling of and exposure to Bloodborne Pathogens.

The Bloodborne Pathogens Control Program is designed to help prevent the spread of HIV and HBV infections to persons who may be reasonably expected to come into contact with blood and other body fluids as part of their work/activities or what is defined by OSHA as an "exposure incident"(see definitions below). It should be noted, however, that there is limited possibility that someone will acquire HIV or the HBV as a result of job-related contact with blood or other body fluids.

Until proven otherwise, all blood and other body fluids will be considered contaminated. For purposes of expediency, future reference to "blood and other body fluids" will simply be stated as "blood."



Human Resources will evaluate the Employee Work Profile (job description) to determine whether a position is to be considered 'at-risk'. A supervisor requesting change of status for any position must request the change from human resources. Vice presidents, division heads, and their supervisory staff will annually identify at risk positions/personnel and ensure that they comply with the appropriate instructions. Human resources will maintain a list of all positions (faculty, staff, and students) that have been designated at risk.

  1. The employee will be notified by his/her supervisor of the time and location for the medical training and the departmental training (see Training section).

  2. After the employee has received both training sessions, he/she is required to take one of the following actions:

    • If the employee decides against the inoculation option, he/she must complete a Declination Form and submit it to the trainer. These forms will be filed in the University Health Center.
    • An employee in an at risk position, may decide at a later time to receive the inoculation. They should contact the university health center to schedule their first inoculation.
    • If the employee chooses to be inoculated, he/she must complete the HBV/HIV Consent form. They will then receive the first of three inoculations from the University Health Center. The employee is responsible for obtaining the second and third inoculations according to the specified time frame.
    • Provide appropriate documentation of previous inoculation series.

Any other faculty, classified employee, wage employee, or student who is exposed to blood or body fluids as a result of performing a "good Samaritan" act during working hours, which is outside of his or her duties is covered for post exposure.

6.2 Persons who begin the inoculation process, but fail to complete the series by the designated time schedule, should consult with one of the UHC RNs responsible for the BBP medical training.


All persons in at risk positions will be given medical and departmental training provided by the university. Human Resources and the University Health Center will coordinate all medical training activity. Human Resources will maintain employee-training records. Human Resources will maintain training records for all student positions designated at risk.

1) Medical Training

This training will be provided by the University Health Center and will include:

  • What are bloodborne pathogens?

  • Who is at risk?

  • What is exposure?

  • How is an exposure incident handled?

  • How does the employee protect himself/herself?

  • Information on the vaccine.

  • Laboratory workers must receive additional specialized training.

2) Department Training

All departments with at risk positions must conduct annual departmental training, including any pertinent updates. Employees must be aware of the HAZMAT (hazardous materials) manual, the OSHA regulations, and the exposure control plan, including where these materials are kept within the department. The training must review the specific exposure control plan developed for the office/department. An outline of an exposure control plan would include:

  • Definition of at risk positions for the department

  • Description of specific job duties/tasks that place the employee at risk (i.e. performing venipunctures, aiding an injured athlete).

  • Description of proper performance of job duties to prevent disease transmission (i.e. proper hand washing, use of barriers such as gloves).

  • Description of engineering and work practice controls which are in place to reduce the likelihood of exposure (i.e. sharps disposal containers, biohazard bags).

  • Description of hazard communication (i.e. warning labels).

  • Description of personal protective equipment available in the departments and its proper use (i.e. latex gloves, goggles).

  • Description of decontamination and disposal procedures of personal protective equipment and infectious waste or materials (i.e. clean-up procedure, proper use of bleach).

  • Description of other protective practices required by the department.

  • Reporting process for an exposure incident.

  • Departmental engineering and work practice controls must be examined and evaluated on a regular basis to ensure their effectiveness.

  • Annual re-evaluation and implementation of safer needle devices as part of the exposure control plan update.

  • Documentation of the involvement of non managerial, front line employees in choosing safer needle devices.


  1. Employees (whether at risk employees or others performing a good Samaritan act who have a potential exposure incident) will contact the designated supervisor. If the exposure is related to BBP, the supervisor will immediately contact the university safety engineer or Workers Compensation coordinator in Human Resources and refer the employee to the University Health Center (during regular hours) or the Rockingham Memorial Hospital Emergency Room for medical evaluation) The supervisor will complete the Blood Borne Pathogen Incident Report available on the HR Website.

  2. Persons may sign a waiver refusing medical assessment and treatment.

  3. If an exposure is validated by medical personnel, an evaluation will include a confidential medical evaluation documenting the circumstances of exposure, identifying and testing the source individual, if feasible, testing the exposed employee's blood, post-exposure inoculations, counseling and evaluation of reported illnesses. The university will cover the associated costs. The results of any tests will be kept confidential and disclosed only with written consent of the exposed individual.

  4. A "Sharps Injury Log" for recording injuries from contaminated sharps will be kept by Human Resources. Incidents should be reported using the "Needle stick Reporting Form" available on the HR website


The medical records for all persons involved in an exposure incident must be maintained for length of employment plus 30 years. All records are confidential. Records must include name and social security number, hepatitis B vaccination status (including dates), results of any examinations, medical testing and follow-up procedures, a copy of the healthcare professional's written opinion, and a copy of information provided to the health care professional. Faculty, classified staff and administrative employee records will be maintained in Human Resources. Student employee records will be maintained in the University Health Center.


7.1 Each department head is responsible for the application and enforcement of the mandated policy in areas under their direction. The office of public safety, director of human resources and the Associate Director of the university Health Center will facilitate compliance with the standard.

7.2 Department heads of at risk personnel are responsible to develop and implement departmental exposure control plans; disseminate awareness information; establish engineering and work practice controls and alert human resources of vacancy in an at risk category or identify new at risk positions.

7.3 All approved costs involved in training, equipment, inoculations, decontamination, post exposure follow-up and like expenses related to this program will be paid by the university through designated budgets.

7.4 The office of public safety and the human resources office will oversee and assure compliance of the Bloodborne Pathogen Control program at the university. The University Health Center in cooperation with Human resources will coordinate and provide the medical training and vaccination administration to all at risk employees.

7.5 Directors/Department heads are responsible for maintaining an accurate record of the status of employees in at risk positions related to medical and departmental operation.


Sanctions will be commensurate with the severity and/or frequency of the offense and may include termination of employment.




The authority to interpret this policy rests with the President, and is generally delegated to the Vice President for Student Affairs.

Original Version: March 1, 1999
Approved: May 2002
Linwood H. Rose, President

Index of Terms





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