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Type: University Policy
Division: Public Safety

Contact Phone Number: 503-838-8481
Contact Email Address: safety@wou.edu

Bloodborne Pathogens Standard
Vice President for Finance and Administration Campus Public Safety

The purpose of this exposure control plan is to:

1. Eliminate or minimize employee occupational exposure to human blood or other body fluids;

2. Identify employees occupationally exposed to blood or Other Potentially Infectious Materials (O.P.I.M.) while performing their regular job duties;

3. To provide employees exposed to blood and O.P.I.M. information and training.  A copy of this plan is available to all employees on Western Oregon University’s web site or through the Occupational / Environmental Safety Division of Campus Public Safety during normal work hours.

4. Comply with OR-OSHA Bloodborne Pathogen Standard, OAR 437-02-1910.1030.

WOU Employees

OAR 437-021910.1030:


OR-OSHA Bloodborne Pathogen Standard 1910.1030:




Western Oregon University is committed to the prevention of incidents or happenings which may result in employee injury and illness: and to comply with the Oregon OSHA Bloodborne Pathogens Standard, OAR 437-02-1910.1030; and through this written exposure control plan, share responsibility to ensure performance under that responsibility; and hereby adopt this exposure control plan as an element of the Safety and Health Program.




Occupational / Environmental Safety have performed an exposure determination for all common job classifications, which may be expected to incur occupational exposures to blood or O.P.I.M. This exposure determination is made without regard to the use of Personal Protective Equipment (P.P.E.). The following is a list of those job classifications in this category:

Reception Nurse                       Custodial Services Coordinator

Staff Nurse                              Plumber

Nurse Practitioner                     Early Childhood Assistant

Registered Nurse 1 and 2           Early Childhood Associate Teacher

Public Safety Officer                   Teaching Assistant

Custodian                                 Natural Science Biology Department

Athletic Trainers                        Athletic Equipment Coordinator

Aquatic Coordinator                   Aquatic Lifeguard


The following is a list of job classifications in which some employees may have occupational exposures. Not all of these employees are expected to incur exposure to blood or O.P.I.M. The job classification, tasks, and procedures are listed below:

Job Classification                                                 Task/Procedure

Athletic Equipment Coordinator                                       Sports-type injuries

Aquatic Lifeguards                                                         Pool type injuries/accidents

Early Childhood Assistant/Teacher                                  Childcare

Plumber                                                                       Body waste

Nurse/Healthcare Provider                                             Blood/body fluids/sharps

Biology Instructor/Lab Technician                                   Body fluids

Custodian                                                                     Blood/body fluids

Public Safety Officer                                                      Blood/body fluids



1. Universal Precautions

Universal precautions recognize all body fluids as though they are infected with bloodborne pathogens. This method of infection control requires the employer and employee to assume that all human blood and specified human body fluids are infectious for HIV, HBV, and other bloodborne pathogens. Where it is difficult or impossible to identify body fluids, all are to be considered potentially infectious.

2. Engineering Controls and Work Practices

Engineering controls and work practices must be used by all employees to eliminate or minimize occupational exposures at Western Oregon University. The following engineering controls are to be followed:

a. Sharps containers must:

 Be puncture resistant;

 Be properly labeled or color-coded for bio-hazards;

 Be leak proof on the sides and bottom; 

 Not allow employees to reach into the container by hand to retrieve sharps;

 Be conveniently located to work area;

 Be maintained in an upright position; and

 Be replaced routinely, and not allowed to overfill.

b. Storage, transportation, or shipping containers must: 

 Be closeable;

 Be properly labeled or color-coded for bio-hazards;

 Be leak proof; and 

 Be puncture resistant. 

The following are work practices to be used by employees with occupational exposure:

a. Wash hands with soap and water immediately or as soon as possible after removing gloves or other personal protective equipment.

b. Flush mucous membranes with water immediately or as soon as possible following contact of such body areas with blood or O.P.I.M.

c. Do not bend, recap or remove contaminated needles unless no alternative is feasible or such action is required by a specific medical or dental procedure.

d. Do not shear or break contaminated needles.

e. If necessary to bend, recap or remove needles, use only a mechanical device or a one-handed technique.

f. Place contaminated re-useable sharps in appropriate containers immediately or as soon as possible after use.

g. Immediately close sharps containers when full. Place in a secondary container if leakage is possible.

h. Do not eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in work areas where there is a reasonable likelihood of occupational exposure.

i. Do not keep food or drink in refrigerators, freezers, shelves, cabinets or on countertops or bench tops where blood or O.P.I.M. are present.

j. Perform procedures involving blood or O.P.I.M. to minimize splashing, spraying, spattering, and generation of droplets.

k. Do not pipette/suction blood or O.P.I.M. by mouth.

l. Place blood or O.P.I.M. only in containers that prevent leaks during collection, handling, processing, storage, transport, or shipping.

m. If a container could be punctured by a specimen, it must be placed in a puncture-resistant secondary container.

n. Examine and properly decontaminate, if feasible, all equipment prior to servicing or shipping.

o. Attach a warning label to all parts or equipment that remain contaminated, and make sure all affected employees, the servicing representative and/or manufacturer, as appropriate, are informed of its status.

p. Wear gloves when you anticipate hand contact with blood, O.P.I.M., mucous membranes, and non-intact skin is anticipated, and when you perform vascular access procedures and/or handle or touch contaminated items or surfaces.

q. Remove disposable gloves as soon as practical when contaminated or as soon as possible when torn, punctured, or ineffective as a barrier. Never wash disposable gloves for re-use.

r. Properly decontaminate utility gloves before re-using. Discard utility gloves if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration.

s. Remove garments immediately or as soon as possible when they are penetrated by blood or O.P.I.M.

t. Remove all personal protective equipment before leaving the work area.

u. Place used personal protective equipment only in designated areas or containers for storage, washing, decontamination or disposal.

v. Do not pick up broken glassware directly with your hands. Use mechanical means such as a dust pan, tongs, or forceps.


3. Personal Protective Equipment (PPE):

The following PPE must be provided by the supervising department at no cost to employees:

a. Body Protection must be worn if gross contamination is present, or resuscitation is required.

b. Gloves and Masks must be worn when there is reasonable anticipation of contact with potentially infectious material (e.g., mucous membrane, non-intact skin, contaminated surfaces).

c. Eye Protection must be worn if a risk of splash, spray or splatter of potentially infectious materials exits.

d. Special PPE (list any specialty type PPE).

The employees’ supervisor is responsible to ensure and issue appropriate, readily accessible PPE, without cost, to employees. Hypoallergenic gloves, glove liners, powder-less gloves, or other similar alternatives will be readily accessible to those employees who are allergic to the gloves normally provided.

All PPE must be removed prior to leaving the work area. All PPE is to be cleaned, laundered, and disposed of by the employer at no cost to the employee. PPE, when removed, must be placed in the department’s designated area for storage, washing, decontamination and disposal. 

4. Housekeeping: 

a. General Housekeeping Procedures:

All equipment, environmental and working surfaces will be cleaned and decontaminated using appropriate disinfectants and procedures as soon as feasible after any contact with blood or O.P.I.M. occurs.

Protective coverings, such as plastic wrap, aluminum foil, or imperviously backed absorbent paper used to cover equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become overtly contaminated, or at the end of the work shift if they may have become contaminated during the shift.

b. Regulated Waste:

Regulated waste is to be placed in containers which are:

 Closeable;

 Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping;

 Labeled or color-coded; and 

 Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.   

c. Contaminated Laundry:

Contaminated laundry shall be handled as little as possible with minimum agitation. It must be bagged or containerized where it was used and must not be sorted or rinsed where it was used.

Contaminated laundry must be placed and transported in bags or containers that are properly labeled for bio-hazards.

When contaminated laundry is wet and could possibly soak through or leak from a bag or container, it must be placed in leak-proof bags or containers.

Employees must wear proper personal protective equipment when handling contaminated laundry.

5. Hepatitis B Vaccine, Post-Exposure Evaluation and Follow-up:

a. Hepatitis B Vaccination:

Western Oregon University will offer, at no cost to exposed employees, the Hepatitis B vaccination series, and the post exposure follow-up to those who have had an exposure incident within ten (10) working days after receiving the initial job assignment. The department is responsible for arranging with the Director of Student Health and Counseling Services for education and/or vaccination.

The department supervisor is to ensure that all medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post exposure follow-up, including prophylaxis / Titer are:

1) Made available at no charge to the employee, at a reasonable place and time;

2) Performed or supervised by a licensed healthcare professional.

b. Post Exposure Evaluation and Follow-up:

When an employee has an exposure incident, it must be reported to the Safety Officer as soon as possible after the incident occurs.

Following the reported exposure incident, the exposed employee will immediately receive a confidential medical evaluation including the following elements:

1)  Made available at no cost.

2)  Made available at a reasonable place and time.

3)  Performed by/or under the supervision of a licensed physician or healthcare professional and

4)  Provided according to recommendations of the US Public Health Service current at the time evaluations and procedures take place.

5)  An accredited laboratory at no cost to the employee conducts all tests.

All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up. The initial evaluation may be provided by medical staff at the Student Health and Counseling Center. Any additional evaluations not performed by the Student Health and Counseling Center need to be performed by employee’s personal care provider or licensed medical professional. All post exposure follow-ups will be performed by the employee’s personal health care provider. 

c. Information Provided to the Healthcare Professional

The Department Supervisor is to ensure that the healthcare professional responsible for the employee’s hepatitis B vaccination is provided the following:

1) A copy of Oregon Administrative Rules 437, Division 2, Subdivision Z, Toxic and Hazardous Substances: Bloodborne Pathogens (19140.1030).

2) A description of the exposed employee’s duties as they relate to the exposure incident;

3) Documentation of the route(s) of exposure and circumstances under which exposure occurred;

4) Results of the source individual’s blood testing, if available; and 

5) All medical records relevant to the appropriate treatment of the employee including vaccination status which are WOU’s responsibility to maintain. 

d.  Healthcare Professional’s Written Opinion

The supervisor must obtain and provide 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 of the HBV vaccination will be limited to whether HBV is indicated for an employee, and if the employee has received such vaccination.

6.  Communication of Hazards

        a. Labels and Signs:

The Occupational/ Environmental Safety Officer will ensure that biohazard labels are on each container of regulated waste according to section (g) of the standard.

Warning labels must be affixed to all containers, including refrigerators and freezers containing blood or OPIM. 

b. Information and Training:

The supervisor, with assistance from the University Safety Officer, will ensure that training is provided at the time of initial assignment to tasks where occupational exposure to blood or OPIM may occur and that it shall be repeated once a year there after. The training program will be tailored to the education and language level of the employee, and offered during the normal work shift. The training will contain the following information: 

1) A copy of the regulation

2) Epidemiology and symptoms of bloodborne diseases

3) Modes of transmission of bloodborne pathogens

4) WOU’s Exposure Control Plan and the means by which the employee can obtain a copy of the written plan:

5) Methods for recognizing tasks that may involve exposure to blood and OPIM,

6) The use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices and personal protective equipment;

7) The types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment;

8) The basis for selection of personal protective equipment;

9) Hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated. 

10) Actions to take and persons to contact in an emergency involving blood or OPIM;

11) Procedure to follow if an exposure incident occurs, including the methods of reporting the incident and the medical follow-up that will be made available;

12) Post-exposure evaluation and follow-up that WOU is required to provide for the employee following an exposure incident;

13) Signs and labels and/or color coding required;

14) An opportunity for interactive questions and answers.

7. Record Keeping

a. Medical Records

The University Safety Office is responsible for maintaining medical records as indicated below. Medical records are strictly confidential, and will not be reported to any person in or out of the workplace without his/her express written consent. These records will be maintained for the duration of the employee’s employment plus 30 years and kept at the Campus Public Safety Department.

1) Name and SSN of employee.

2) A copy of the employee’s hepatitis B vaccination status including the dates of all the hepatitis B vaccinations and may include medical records relative to the employee’s ability to receive vaccination;

3) A copy of all results of examinations, medical testing, and follow-up procedures;

4) WOU’s copy of the healthcare professional’s written opinion; and

5) A copy of the information to the healthcare professional.

LAST UPDATED: 08/11/2016



SOURCE:    Previously Referred to as: FA-CPS-002
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