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SAMPLE WRITTEN PROGRAM

BLOODBORNE PATHOGENS EXPOSURE CONTROL PROGRAM

OSHA Consultation Program

WI State Laboratory of Hygiene

Sample Exposure Control Program Page i

BLOODBORNE PATHOGENS EXPOSURE CONTROL PROGRAM

TABLE OF CONTENTS

A. Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

B. Exposure Determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

C. Implementation Schedule and Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . 21. Compliance Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22. Needles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33. Containers for REUSABLE Sharps . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44. Work Area Restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45. Specimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46. Contaminated Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57. Personal Protective Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58. Housekeeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79. Regulated Waste Disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810. Laundry Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911. Hepatitis B Vaccine and Post-Exposure Evaluation and Follow-Up . 1012. Labels and Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1413. Information and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1514. Recordkeeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1615. Evaluation and Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1916. Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1917. Outside Contractors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Page ii Sample Exposure Control Program

ACKNOWLEDGMENTS

This document was compiled by the staff of the OSHA Health ConsultationProgram in the WI State Laboratory of Hygiene. It relies heavily on sampleplans from federal OSHA Region III and the Indian Health Service. Foradditional assistance see our website at http://www.slh.wisc.edu/wocp

Note: This sample plan is provided only as a guide to assist in complyingwith 29 CFR 1910.1030, OSHA's Bloodborne Pathogens standard. It is notintended to supersede the requirements detailed in the standard. Employers should review the Standard for particular requirements whichare applicable to their specific situation. It should be noted that this sampleprogram does not include provisions for HIV/HBV laboratories and researchfacilities which are addressed in section (e) of the Standard. Employersoperating these laboratories need to include provisions as required by theStandard. Employers will need to add information relevant to theirparticular facility in order to develop an effective, comprehensive exposurecontrol plan. Employers should note that their exposure control plans areexpected to be reviewed at least on an annual basis and updated whennecessary.

This document and safety and health consultation services are providedfree of charge to owners, proprietors, and managers of small businesses,by the Wisconsin State Laboratory of Hygiene under a program fundedlargely by the Occupational Safety and Health Administration (OSHA), anagency of the U.S. Department of Labor.

The information contained in this document is not considered a substitutefor any provision of the standard.

Rev: March 2005

1The employer must have a plan for each facility or establishment.

Sample Exposure Control Program Page 1

BLOODBORNE PATHOGENSEXPOSURE CONTROL PLAN

Facility Name1: _____________________________________

Date of Preparation: ___________________________

In accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR1910.1030, the following exposure control plan has been developed:

A. Purpose

The purpose of this exposure control plan is to:

1. Eliminate or minimize employee occupational exposure toblood or certain other body fluids;

2. Comply with the OSHA Bloodborne Pathogens Standard, 29CFR 1910.1030.

B. Exposure Determination

OSHA requires employers to perform an exposure determinationconcerning which employees may incur occupational exposure to blood orother potentially infectious materials. The exposure determination is madewithout regard to the use of personal protective equipment (i.e. employeesare considered to be exposed even if they wear personal protectiveequipment). This exposure determination is required to list all jobclassifications in which all employees may be expected to incur suchoccupational exposure, regardless of frequency. At this facility the followingjob classifications are in this category:

(list job classifications) ___________________________________________________________________________________________________________________________________________________

_______________________________________________________

Sample Exposure Control Program

In addition, OSHA requires a listing of job classifications in which someemployees may have occupational exposure. Since not all the employeesin these categories would be expected to incur exposure to blood or otherpotentially infectious materials, task or procedures that would cause theseemployees to have occupational exposure are also required to be listed inorder to clearly understand which employees in these categories areconsidered to have occupational exposure. The job classifications andassociated tasks for these categories are as follows (or place in appendix):

Job Classification Task/Procedure

___________________________ ________________________________________________ ________________________________________________ ________________________________________________ _____________________

C. Implementation Schedule and Methodology

OSHA also requires that this plan include a schedule and method ofimplementation for the various requirements of the standard. The followingcomplies with this requirement:

1. Compliance Methods

Universal precautions will be observed at this facility in order to preventcontact with blood or other potentially infectious materials. All blood orother potentially infectious material will be considered infectious regardlessof the perceived status of the source individual.

Engineering and work practice controls will be utilized to eliminate orminimize exposure to employees at this facility. Where occupationalexposure remains after institution of these controls, personal protectiveequipment shall also be utilized. At this facility the following engineeringcontrols will be utilized: (list controls, such as sharps containers, biosafetycabinets, “needle-less” IV systems, syringes with retracting needles,Blunting IV catheter, etc.)_____________________________________________________________________________________________________________________________________________________________________

The listed controls will be examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is as follows: (list schedule such as daily, once/week, etc. as well as list the job title of the


position which has the responsibility to review the effectiveness of theindividual controls, such as the supervisor for each department, etc.)_____________________________________________________________________________________________________________________________________________________________________

Handwashing facilities shall be made available to the employees who incurexposure to blood or other potentially infectious materials. OSHA requiresthat these facilities be readily accessible after incurring exposure. (Ifhandwashing facilities are not feasible, the employer is required to provideeither an antiseptic cleanser in conjunction with clean cloth/paper towels orantiseptic towelettes. If these alternatives are used then the hands are tobe washed with soap and running water as soon as feasible. Employerswho must provide alternatives to readily accessible handwashing facilitiesshould list the location, tasks, and responsibilities to ensure maintenanceand accessibility of these alternatives.)

____________________ (insert name of position/person, e.g. supervisors)shall ensure that after the removal of personal protective gloves, employeesshall wash hands and any other potentially contaminated skin areaimmediately or as soon as feasible with soap and water.

____________________ (insert name of position/person, e.g. supervisors)shall ensure that if employees incur exposure to their skin or mucousmembranes then those areas shall be washed or flushed with water assoon as feasible following contact.

2. Needles

Contaminated needles and other contaminated sharps will not be bent,recapped, removed, sheared or purposely broken. OSHA allows anexception to this if the procedure would require that the contaminatedneedle be recapped or removed and no alternative is feasible and theaction is required by the medical procedure. If such action is required thenthe recapping or removal of the needle must be done by the use of amechanical device or a one-handed technique. At this facility recapping orremoval is only permitted for the following procedures: (List the proceduresand also list the mechanical device to be used or alternately if a one-handed technique will be used.)_____________________________________________________________________________________________________________________________________________________________________


3. Containers for REUSABLE Sharps

Contaminated sharps that are reusable are to be placed immediately, or assoon as possible, after use into appropriate sharps containers. At thisfacility the sharps containers are puncture resistant, labeled with abiohazard label and are leak proof. (List here where reusable sharpscontainers are located as well as who has responsibility for removingsharps from containers and how often the containers will be checked toremove the sharps.)_____________________________________________________________________________________________________________________________________________________________________

4. Work Area Restrictions

In work areas where there is a reasonable likelihood of exposure to blood orother potentially infectious materials, employees are not to eat, drink, applycosmetics or lip balm, smoke, or handle contact lenses. Food andbeverages are not to be kept in refrigerators, freezers, shelves, cabinets, oron counter tops or bench tops where blood or other potentially infectiousmaterials are present.

Mouth pipetting/suctioning of blood or other potentially infectious materialsis prohibited.

All procedures will be conducted in a manner which will minimize splashing,spraying, splattering, and generation of droplets of blood or other potentiallyinfectious materials. Methods which will be employed at this facility toaccomplish this goal are: (List methods, such as covers on centrifuges,usage of dental dams if appropriate, etc.)

5. Specimens

Specimens of blood or other potentially infectious materials will be placed ina container which prevents leakage during the collection, handling,processing, storage, and transport of the specimens.

The container used for this purpose will be labeled or color coded inaccordance with the requirements of the OSHA standard. (Note that theStandard provides for an exemption for specimens from the labeling/colorcoding requirement of the standard provided that the facility utilizesuniversal precautions in the handling of all specimens and the containersare recognizable as containing specimens. This exemption applies only


while the specimens remain in the facility. If the employer chooses to usethis exemption then it should be stated here. ____________________)

Any specimens which could puncture a primary container will be placedwithin a secondary container which is puncture resistant.

If outside contamination of the primary container occurs, the primarycontainer shall be placed within a secondary container which preventsleakage during the handling, processing, storage, transport, or shipping ofthe specimen.

6. Contaminated Equipment

____________________ (insert name of position/person) is responsible forensuring that equipment which has become contaminated with blood orother potentially infectious materials shall be examined prior to servicing orshipping and shall be decontaminated as necessary unless thedecontamination of the equipment is not feasible.

7. Personal Protective Equipment

PPE Provision

____________________ (insert name of position/person) isresponsible for ensuring that the following provisions are met.

All personal protective equipment used at this facility will be providedwithout cost to employees. Personal protective equipment will bechosen based on the anticipated exposure to blood or otherpotentially infectious materials. The protective equipment will beconsidered appropriate only if it does not permit blood or otherpotentially infectious materials to pass through or reach theemployees' clothing, skin, eyes, mouth, or other mucous membranesunder normal conditions of use and for the duration of time which theprotective equipment will be used. (Indicate how clothing will beprovided to employees, e.g. who has responsibility for distribution.Employers could also list which procedures would require theprotective clothing and the recommended type of protection required,this could also be listed as an appendix to this program.)


PPE Use

____________________ (insert name of position/person) shallensure that the employee uses appropriate PPE unless thesupervisor shows that employee temporarily and briefly declined touse PPE when under rare and extraordinary circumstances, it wasthe employee's professional judgement that in the specific instanceits use would have prevented the delivery of healthcare or posed anincreased hazard to the safety of the worker or co-worker. When theemployee makes this judgement, the circumstances shall beinvestigated and documented in order to determine whether changescan be instituted to prevent such occurrences in the future.

PPE Accessibility

____________________ (insert name of position/person) shallensure that appropriate PPE in the appropriate sizes is readilyaccessible at the work site or is issued without cost to employees. Hypoallergenic gloves, glove liners, powderless gloves, or othersimilar alternatives shall be readily accessible to those employeeswho are allergic to the gloves normally provided.

PPE Cleaning, Laundering and Disposal

All personal protective equipment will be cleaned, laundered, anddisposed of by the employer at no cost to the employees. All repairsand replacements will be made by the employer at no cost toemployees.

All garments which are penetrated by blood shall be removedimmediately or as soon as feasible. All ppe will be removed prior toleaving the work area.

When PPE is removed, it shall be placed in an appropriatelydesignated area or container for storage, washing, decontaminationor disposal.

Gloves

Gloves shall be worn where it is reasonably anticipated thatemployees will have hand contact with blood, other potentiallyinfectious materials, non-intact skin, and mucous membranes; when


performing vascular access procedures and when handling ortouching contaminated items or surfaces.

Disposable gloves used at this facility are not to be washed ordecontaminated for re-use and are to be replaced as soon aspractical when they become contaminated or as soon as feasible ifthey are torn, punctured, or when their ability to function as a barrieris compromised. Utility gloves may be decontaminated for re-useprovided that the integrity of the glove is not compromised. Utilitygloves will be discarded if they are cracked, peeling, torn, punctured,or exhibit other signs of deterioration or when their ability to functionas a barrier is compromised.

Eye and Face Protection

Masks in combination with eye protection devices, such as gogglesor glasses with solid side shield, or chin length face shields, arerequired to be worn whenever splashes, spry platter, or droplets ofblood or other potentially infectious materials may be generated andeye, nose, or mouth contamination can reasonably be anticipated. Situations at this facility which would require such protection are asfollows:

________________________________________________________________________________________________________________________________________________

Additional Protection

Additional protective clothing (such as lab coats, gowns, aprons,clinic jackets, or similar outer garments) shall be worn in instanceswhen gross contamination can reasonably be anticipated (such asautopsies and orthopedic surgery). The following situations requirethat such protective clothing be utilized:

8. Housekeeping

This facility will be cleaned and decontaminated according to the followingschedule: (list area and schedule)


AREA Schedule Cleaner____________________ ________________ _________________________________ ________________ _________________________________ ________________ _________________________________ ________________ _____________

Decontamination will be accomplished by utilizing the following materials: (list the materials which will be utilized, such as bleach solutions or EPAregistered germicides)_____________________________________________________________________________________________________________________________________________________________________

All contaminated work surfaces will be decontaminated after completion ofprocedures and immediately or as soon as feasible after any spill of bloodor other potentially infectious materials, as well as the end of the work shiftif the surface may have become contaminated since the last cleaning. (Employers should add in any information concerning the usage ofprotective coverings, such as plastic wrap which they may be using toassist in keeping surfaces free of contamination.)

All bins, pails, cans, and similar receptacles shall be inspected anddecontaminated on a regularly scheduled basis (list frequency _________and by position/person ____________________)

Any broken glassware which may be contaminated will not be picked updirectly with the hands.

Reusable sharps that are contaminated with blood or other potentiallyinfectious materials shall not be stored or processed in a manner thatrequires employees to reach by hand into the containers where thesesharps have been placed.

9. Regulated Waste Disposal

Disposable Sharps

Contaminated sharps shall be discarded immediately or as soon asfeasible in containers that are closable, puncture resistant, leak proofon sides and bottom and labeled or color coded.

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


immediate area where sharps are used or can be reasonablyanticipated to be found (e.g., laundries).

The containers shall be maintained upright throughout use andreplaced routinely and not be allowed to overfill.

When moving containers of contaminated sharps from the area ofuse, the containers shall be closed immediately prior to removal orreplacement to prevent spillage or protrusion of contents duringhandling, storage, transport, or shipping.

The container shall be placed in a secondary container if leakage ofthe primary container is possible. The second container shall becloseable, constructed to contain all contents and prevent leakageduring handling, storage and transport, or shipping. The secondcontainer shall be labeled or color coded to identify its contents.

Reusable containers shall not be opened, emptied, or cleanedmanually or in any other manner which would expose employees tothe risk of percutaneous injury.

Other Regulated Waste

Other regulated waste shall be placed in containers which arecloseable, constructed to contain all contents and prevent leakage offluids during handling, storage, transportation or shipping.

The waste must be labeled or color coded and closed prior toremoval to prevent spillage or protrusion of contents during handling,storage, transport, or shipping.

(Please note: Disposal of all regulated waste shall be in accordancewith applicable Unites States, state and local regulations. The DNRis the controlling agency in Wisconsin.)

10. Laundry Procedures

Laundry contaminated with blood or other potentially infectious materialswill be handled as little as possible. Such laundry will be placed inappropriately marked (biohazard labeled, or color coded red bag) bags atthe location where it was used. Such laundry will not be sorted or rinsed inthe area of use.


(Please note: If your facility utilized Body Substance Isolation orUniversal Precautions in the handling of all soiled laundry (i.e. alllaundry is assumed to be contaminated) no labeling or color-codingis necessary if all employees recognize the hazards associated withthe handling of this material.)

Laundry at this facility will be cleaned at ________________________.

(Please note: If your facility ships contaminated laundry off-site to asecond facility which does not utilize Universal Precautions in thehandling of all laundry, contaminated laundry must be placed in bagsor containers which are labeled or color-coded. One possiblesolution would be to include a requirement in the contract laundryscope of work requiring the laundry to utilize the equivalent ofUniversal Precautions.)

11. Hepatitis B Vaccine and Post-Exposure Evaluation andFollow-Up

General

The (insert company name) ____________________ shall makeavailable the Hepatitis B vaccine and vaccination series and antibodytesting as appropriate to all employees who have occupationalexposure, and post exposure follow-up to employees who have hadan exposure incident.

The (insert position/person) ____________________ shall ensurethat all medical evaluations and procedures including the Hepatitis Bvaccine and vaccination series and post exposure follow-up,including prophylaxis are:

a.) Made available at no cost to the employee;

b.) Made available to the employee at a reasonable timeand place;

c.) Performed by or under the supervision of a licensedphysician or by or under the supervision of anotherlicensed healthcare professional; and

d.) Provided according to the recommendations of the U.S.Public Health Service.


All laboratory tests shall be conducted by an accredited laboratory atno cost to the employee.

Hepatitis B Vaccination

____________________ (insert name of position/person) is incharge of the Hepatitis B vaccination program. (Or, whereappropriate: We contract with ____________________ to providethis service.)

Hepatitis B vaccination shall be made available after the employeehas received the training in occupational exposure (see informationand training) and within 10 working days of initial assignment to allemployees who have occupational exposure unless the employeehas previously received the complete Hepatitis B vaccination series,antibody testing has revealed that the employee is immune, or thevaccine is contraindicate for medical reasons.

Participation in a pre-screening program shall not be a prerequisitefor receiving Hepatitis B vaccination.

If the employee initially declines Hepatitis B vaccination but at a laterdate while still covered under the standard decides to accept thevaccination, the vaccination shall then be made available.

All employees who decline the Hepatitis B vaccination offered shallsign the OSHA required waiver indicating their refusal.

If a routine booster dose of Hepatitis B vaccine is recommended bythe U.S. Public Health Service at a future date, such booster dosesshall be made available.

One to two months following the HBV vaccination series, healthcareworkers (with contact with patients or blood and ongoing risk ofsharps injuries) will be tested for HBV surface antigens as indicatedin MMWR.

Antibody testing for response to hepatitis B surface antigen will beprovided by ( List Healthcare Professional or Facility ) at ( Location ).


Post Exposure Evaluation and Follow-up

All exposure incidents shall be reported, investigated, anddocumented. When the employee incurs an exposure incident, itshall be reported to (list who has responsibility for investigation ofexposure incidents): ______________________

Following a report of an exposure incident, the exposed employeeshall immediately receive a confidential medical evaluation andfollow-up, including at least the following elements:

a.) Documentation of the route of exposure, and thecircumstances under which the exposure incidentoccurred;

b.) Identification and documentation of the sourceindividual, unless it can be established thatidentification is infeasible or prohibited by state or locallaw. (Employers may need to modify this provision inaccordance with applicable local laws on this subject. Modifications should be listed here):_______________________________________

c.) The source individual's blood shall be tested as soonas feasible and after consent is obtained in order todetermine HBV and HIV infectivity. If consent is notobtained, the (insert name of position/person) ____________________ shall establish that legallyrequired consent cannot be obtained. When thesource individual's consent is not required by law, thesource individual's blood, if available, shall be testedand the results documented.

d.) When the source individual is already known to beinfected with HBV or HIV, testing for the sourceindividual's known HBV or HIV status need not berepeated.

e.) Results of the source individual's testing shall be madeavailable to the exposed employee, and the employeeshall be informed of applicable laws and regulationsconcerning disclosure of the identity and infectiousstatus of the source individual.


Collection and testing of blood for HBV and HIV serological statuswill comply with the following:

a.) The exposed employee's blood shall be collected assoon as feasible and tested after consent is obtained;

b.) The employee will be offered the option of having theirblood collected for testing of the employees HIV/HBVserological status. The blood sample will be preservedfor up to 90 days to allow the employee to decide if theblood should be tested for HIV serological status.

All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHAstandard. All post exposure follow-up will be performed by (insertname of clinic, physician, department) ____________________.

Information Provided TO the Healthcare Professional

The (insert name of position/person) ____________________ shallensure that the healthcare professional responsible for theemployee's Hepatitis B vaccination is provided with the following:

a.) A copy of 29 CFR 1910.1030; (While the standardoutlines the confidentiality requirements of the healthcare professional, it might be helpful for the employerto remind that individual of these requirements.)

b.) A written description of the exposed employee's dutiesas they relate to the exposure incident;

c.) Written documentation of the route of exposure andcircumstances under which exposure occurred;

d.) Results of the source individuals blood testing, ifavailable; and

e.) All medical records relevant to the appropriatetreatment of the employee including vaccination status.


Healthcare Professional's Written Opinion

The (insert name of position/person) ____________________ shallobtain and provide the employee with a copy of the evaluatinghealthcare professional's written opinion within 15 days of thecompletion of the evaluation.

The healthcare professionals written opinion for HBV vaccinationshall be limited to whether HBV vaccination is indicated for anemployee, and if the employee has received such vaccination.

The healthcare professional's written opinion for post exposurefollow-up shall be limited to the following information:

a.) A statement that the employee has been informed ofthe results of the evaluation; and

b.) A statement that the employee has been told about anymedical conditions resulting from exposure to blood orother potentially infectious materials which requirefurther evaluation or treatment.

Note: All other findings or diagnosis shall remain confidential andshall not be included in the written report.

12. Labels and Signs

____________________ (insert name of position/person) shallensure that biohazard labels shall be affixed to containers ofregulated waste, refrigerators and freezers containing blood or otherpotentially infectious materials, and other containers used to store,transport or ship blood or other potentially infectious materials.

The universal biohazard symbol shall be used. The label shall befluorescent orange or orange-red.

Red bags or containers may be substituted for labels. However,regulated wastes must be handled in accordance with the rules andregulations of the organization having jurisdiction.

Blood products that have been released for transfusion or otherclinical use are exempted from these labelling requirements.


13. Information and Training

____________________ (insert name of position/person) shallensure that training is provided at the time of initial assignment totasks where occupational exposure may occur, and that it shall berepeated within twelve months of the previous training. Trainingshall be tailored to the education and language level of theemployee, and offered during the normal work shift. The training willbe interactive and cover the following:

a.) A copy of the standard and an explanation of itscontents;

b.) A discussion of the epidemiology and symptoms ofbloodborne diseases including HIV, HBV and HCV;

c.) An explanation of the modes of transmission ofbloodborne pathogens;

d.) An explanation of the ____________________ (insertcompany name) Bloodborne Pathogen ExposureControl Plan (this program), and a method for obtaininga copy.

e.) The recognition of tasks that may involve exposure.

f.) An explanation of the use and limitations of methods toreduce exposure, for example engineering controls,work practices and personal protective equipment(PPE), including specific training on engineered sharpsused in the facility.

g.) Information on the types, use, location, removal,handling, decontamination, and disposal of PPEs.

h.) An explanation of the basis of selection of PPEs.

i.) Information on the Hepatitis B vaccination and antibodytesting, including efficacy, safety, method ofadministration, benefits, and that it will be offered freeof charge.

j.) Information on the appropriate actions to take andpersons to contact in an emergency involving blood orother potentially infectious materials.


k.) An explanation of the procedures to follow if anexposure incident occurs, including the method ofreporting and medical follow-up.

l.) Information on timely reporting of an exposure incidentso that chemical prophylaxis, if appropriate, can beadministered in a timely manner in order to beeffective.

m.) Information on the evaluation and follow-up requiredafter an employee exposure incident.

n.) An explanation of the signs, labels, and color codingsystems.

The person conducting the training shall be knowledgeable in thesubject matter.

Employees who have received training on bloodborne pathogens inthe twelve months preceding the effective date of this policy shallonly receive training in provisions of the policy that were not covered.

Additional training shall be provided to employees when there areany changes of tasks or procedures affecting the employee'soccupational exposure.

14. Recordkeeping

Medical Records

____________________ (insert name of position/person) isresponsible for maintaining medical records as indicated below. These records will be kept (insert location) ____________________. (If the employer contracts for post exposure follow-up and HepatitisB vaccination evaluation, make sure that the contract languageincludes provisions for recordkeeping which are consistent with therequirements of 1910.20.)

Medical records shall be maintained in accordance with OSHAStandard 29 CFR 1910.20. These records shall be kept confidential,


and must be maintained for at least the duration of employment plus30 years. The records shall include the following:

a.) The name and social security number of the employee.

b.) A copy of the employee's HBV vaccination status,including the dates of vaccination.

c.) A copy of all results of examinations, medical testing,and follow-up procedures.

d.) A copy of the information provided to the healthcareprofessional, including a description of the employee'sduties as they relate to the exposure incident, anddocumentation of the routes of exposure andcircumstances of the exposure.

OSHA Injury and Illness Log (OSHA-300)

( Name of responsible person or department ) is responsible formaintaining and updating the OSHA-300 log of workplace injuriesand illnesses.

All work related needlestick injuries and cuts from sharp objects thatare contaminated with blood or OPIM are recorded as an injury onthe OSHA Injury and Illness log.

A non-sharps exposure incident is evaluated to determine if the casemeets OSHA's Recordkeeping Requirements (29 CFR 1904). If so, itis recorded on the OSHA Injury and Illness log.

The privacy of employees will be protected by not recording thenames of individuals on the OSHA Injury and Illness log (OSHA-300).

All other provisions of the OSHA recordkeeping rules (29 CFR 1904)will be followed.

Sharps Injury Log

( Name of responsible person or department ) shall maintain asharps injury log for the recording of per-cutaneous injuries fromcontaminated sharps. The information in the sharps injury log shallbe recorded and maintained in such manner as to protect the


confidentiality of the injured employee. The sharps injury log shallcontain, at a minimum:

a.) the type and brand of device involved in the incident,

b.) the department or work area where the exposure incidentoccurred, and

c.) an explanation of how the incident occurred.

Training Records

____________________ (insert name of position/person) isresponsible for maintaining the following training records. Theserecords will be kept (insert location) ____________________.

Training records shall be maintained for three years from the date oftraining. The following information shall be documented:

a.) The dates of the training sessions;

b.) An outline describing the material presented;

c.) The names and qualifications of persons conductingthe training;

d.) The names and job titles of all persons attending thetraining sessions.

Availability

All employee records shall be made available to the employee inaccordance with 29 CFR 1910.20.

All employee records shall be made available to the AssistantSecretary of Labor for the Occupational Safety and HealthAdministration and the Director of the National Institute forOccupational Safety and Health upon request.


Transfer of Records

If this facility is closed or there is no successor employer to receiveand retain the records for the prescribe period, the Director of theNIOSH shall be contacted for final disposition.

15. Evaluation and Review

____________________ (insert name of position/person) isresponsible for annually reviewing this program, and itseffectiveness, and for updating this program as needed.

The annual update documentation will include:

1. an assessment of technology changes that can reduceexposures;

2. an assessment of appropriate commercially available andeffective safer medical devices designed to eliminate orminimize occupational exposure;

3. methods used for soliciting the input from non-managerialhealth care workers in the identification, evaluation andselection of effective engineering and work practicecontrols.

16. Dates

All provisions required by this standard will be implemented by:(insert date for implementation of the provisions of the standard).

17. Outside Contractors

(While the written exposure control plan does not have to addressinformation obtained from and provided to outside contractors, youmay wish to establish standard operating procedures for thesesituations and append them to this document.)

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