Bloodborne Pathogens

The following plan is designed to bring Drury University in compliance with OSHA regulations 29 CFR 1910.1030.   It will serve as the written exposure control plan for Drury University.


The following program will apply to any Drury University employee with possible risk of occupational exposure to potentially infectious materials as defined below. In addition, the post exposure part of this program will apply to all university employees who experience an exposure incident as a result of performance of their duties. This written program will be available to any employee upon request and will be provided to departments who have employees identified in the exposure determination.


Departmental.   Departments will be responsible for carrying out the Bloodborne Pathogens Exposure Control Plan in accordance with this written program and for funding program expenses such as immunizations. Departments will be responsible for conducting employee training and coordinating the disposal of infectious waste materials. Departments will also be responsible for keeping the Safety Director informed of any necessary addendum changes.  

Supervisor .   Supervisors will be responsible for identifying employees with risk of occupational exposure, assuring that employees are aware of and following this written program, and immediately notifying the Safety Director of any occupational exposure incident. It is also the supervisor's responsibility to assure each employee receives annual training from the Safety Director.

Employees .   Employees will be responsible for complying with procedures established by their supervisors in accordance with this program to minimize the risk of exposure. Employees are also responsible for informing their supervisors of an exposure incident.

Safety Director .   The Safety Director will be responsible for administering and managing the bloodborne pathogens program, assisting departments in evaluating potential exposures, maintaining employee medical records as per this program, and making necessary program revisions.


Exposure Incident is a specific eye, mouth, other mucous membrane or non-intact skin contact with blood or other potentially infectious materials that result from the performance of one's duties.

Occupational Exposure is reasonably anticipated skin, eye, mucous membrane or non-intact skin contact with blood or other potentially infectious materials that may result from the performance of any employee's duties. A covered employee will have a position description that specifically describes the duties involving occupational exposure.

Other Potentially Infectious Materials includes the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, and amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. Also, any unfixed human tissue or organ or HIV containing cells or tissue cultures from experimental animals.

Regulated Waste is liquid or semi-liquid blood or other potentially infectious material, contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed, items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling, contaminated sharps and pathological and microbiological wastes containing blood or other potentially infectious materials.

Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.  

Exposure Determination

The following departments within Drury University have employees who may have occupational exposure during the course of performing their duties:

  • Facilities Services
  • Athletics Department
  • Housing
  • Safety and Security
  • Sciences

Methods of Compliance

Universal precautions will be used to prevent contact with blood or other potentially infectious materials by those involved in this program whenever possible. When distinction between body fluids is not possible, the material will be considered potentially infectious.

1. Engineering Controls.

Whenever practical, engineering controls will be used to eliminate or minimize exposure. When employed, engineering controls will be reviewed by supervisors on a periodic basis to ensure their effectiveness.

2.   Work Practices.

  • Whenever possible, employees will be provided with easily accessible hand washing facilities. When this is not possible, employees will be provided with antiseptic hand cleanser or towelettes in first aid kits for use until a sink with hot and cold running water, soap, and disposable towels is accessible.
  • Employees will wash their hands immediately or as soon as feasible after removing gloves or other personal protective equipment. In the event of contact with blood or other potentially infectious materials the eyes, nose, or mouth, those mucous membranes will be flushed with water immediately or as soon as feasible.
  • All contaminated sharps will be placed in appropriate containers immediately or as soon as possible after use. These containers will be puncture resistant, leak proof on the sides and bottoms, and labeled or color coded as per OSHA regulations. Sharps which are reusable shall not be stored in such a manner that employees will be required to reach into the containers. Sharps containers are available from Science Stores or other commercial sources.
  • Eating, drinking, smoking, applying cosmetics (including lip balm) or handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
  • Food and drink will not be allowed in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or other potentially infectious materials are present.
  • Procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances.
  • Mouth pipetting or suctioning of blood or other potentially infectious materials is prohibited.
  • Specimens of blood or other potentially infectious materials will be placed in containers which prevent leakage during collection, handling, processing (TSC), storage, transport, or shipping. The following items will have a biohazard tag or be stored in a red bag or container: Regulated waste that has not been decontaminated, refrigerators or freezers used to store blood or other potentially infectious material, and contaminated equipment or containers used to store, transport, or ship blood or other potentially infectious materials.
  • Departments may choose to substitute red bags or red containers for labels. Transport, shipment, or disposal may require additional labeling.
  • If the primary container leaks or becomes contaminated, employees will put the containers in a secondary container which meets the above criteria. Containers will be available for purchase through Science Stores as well as private commercial sources.
  • Equipment which may become contaminated with blood or other potentially infectious materials will be examined prior to servicing or shipping and decontaminated as necessary. If the equipment cannot be decontaminated, it shall be tagged with biohazard labels and all persons to come into contact with the equipment shall be informed as of the hazard as well as to which pieces of the equipment are contaminated.

3.   Personal Protective Equipment.

Personal protective equipment will be used when appropriate to protect employees from potential occupational exposure incidents. Equipment will be provided to employees at no cost. Appropriate sizes of personal protective equipment will be available to employees, and, when necessary, hypoallergenic gloves or similar alternative will be provided. The specific equipment for the situation will be determined by the department in which the potential for occupational exposure occurs and may include gowns, lab coats, face shields, masks, eye protection and mouthpieces or pockets masks. At a minimum, gloves will be used whenever there is a reasonable anticipation of hand contact with blood or other potentially infectious materials. Appropriate means capable of preventing blood or other potentially infectious materials from passing through or reaching the employee's skin, mucous membranes, or clothes under normal conditions of use.

When circumstances dictate that personal equipment cannot be worn, employees will report the incident to their supervisor who will investigate and document the situation to determine whether changes in work practices, or personal protective equipment is required. When necessary, appropriate follow up action will occur.

Employees will be instructed on the proper disposition of their personal protective equipment. In most cases, employees will be encouraged to discard any disposable personal protective equipment after use.   In all cases, disposable gloves will be discarded and replaced as soon as practical when in disrepair or contaminated. For reusable equipment, cleaning and disinfection will occur; specific training will be provided to employees. In no case will employees be allowed to wear their personal protective equipment outside the work area.

Employees will also be instructed to replace their personal protective equipment as often as necessary. These replacements will be available at no cost to the employee. At a minimum, this will occur after each use where the equipment becomes contaminated and cannot be decontaminated effectively, and when equipment becomes old and ineffective.

4.   Housekeeping

Generally, departments are responsible to ensure that the work site is maintained in a clean and sanitary condition. Departments will implement an appropriate written schedule for cleaning and method of decontamination which best suits their situations. This will include an explanation of the cleaning and decontamination of equipment which has been in contact with blood or other potentially infectious materials.

Contaminated laundry will be handled as little as possible. This will apply to the Athletic Department. By OSHA definition, this does not apply to gym towels and gym shorts under normal conditions. Contaminated laundry from Athletic training will be bagged at the location and identified as a biohazard. If a hazard of soaking through exists, the laundry will be double bagged.

Individual departments will make their own laundry arrangements which will include documentation that the laundry facility uses Universal Precautions in handling the linen.

5.   Regulated Waste

Waste generated during the course of work with potentially infectious materials will be disposed of through an approved hauler to a facility approved by Facilities Services. Other than sharps, those materials which meet the definition of those rules will be immediately transferred upon generation into a red biohazard bag. Bags will be closable, constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping and closed prior to removal to prevent spillage or protrusion of contents at any time. If there is a potential for spillage, a secondary container will be provided.

Sharps will be disposed of in a sharps container which will be closable, puncture resistant, leak proof on both sides and bottom and labeled or color coded as per this plan. During use, the containers will be easily accessible to employees and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found. Sharps containers will be maintained in an upright position and routinely replaced to avoid overfill. When sharps containers are moved, they will be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents. If leakage is a possibility, a secondary container shall be provided which is close-able, constructed to contain all contents and labeled as per this plan.

Waste material which does not meet OSHA definition of regulated waste will be put in either a zip lock bag or a plastic garbage bag, sealed and disposed of in the normal waste stream.

Decontamination Procedures

Generally, decontamination of equipment and the surrounding area will be the responsibility of the department involved in the task. However, in those situations where there is no clear responsibility for the situation, Facilities Services will clean up and decontaminate the area.

Hepatitis B Vaccine

University departments will make the Hepatitis B vaccine series available at no cost to employees who have been identified in this plan as having occupational exposure. The vaccine series will be explained at the employee training session held prior to the effective date of the OSHA regulation or within 10 days of initial assignment of the duties which may result in potential exposure. Facilities Services will coordinate the vaccines.

Employees identified in the exposure determination will be asked to sign the University's Hepatitis B vaccination wavier. This waiver will notify employees that should they decline to accept the vaccine, yet experience continued occupational exposure, they can at any time ask for and receive the vaccine series without cost to the employee. If employees who are not identified as having the potential for exposure have an exposure, they will receive the same follow-up treatment as employees who are pre-identified.

Post-Exposure Evaluation and Follow-up

Drury University will make a post-exposure evaluation and follow up immediately available to any employee who has experienced and occupational exposure incident.

In the event of an occupational exposure, the employee will fill out an Accident Form. This form should be routed through normal channels.

The supervisor will immediately contact the Safety Director upon the knowledge of an exposure incident. They will then conduct an accident investigation and attempt to identify the source of any potentially infectious materials. If the source individual did not consent to having their blood drawn for testing, the University will confirm that consent could not legally be obtained. Employees will have an initial evaluation with appropriate lab analysis at the Family Medical Center. The employee can then make an informed choice regarding post-exposure immunization.

Regardless of whether the source individual can be identified immediate or not, employees will be advised to seek medical consultation within 2 hours of the exposure.

Labels and Signs

Warning labels will be affixed to containers or regulated waste, refrigerators and freezers containing blood or other potentially infectious materials and other containers used to store, transport or ship blood or other potentially infectious materials. Red bags or red containers may substitute for labels.

Information and Training

Departments within the University will be responsible for assuring that their employees receiving training in Bloodborne Pathogens. Training for compliance with the OSHA regulation will be done by designated staff. Training will be done at no cost to the employee and will be conducted during working hours or the employee will otherwise be compensated for the time training.

Training will be provided to employees at the time of the initial assignment to the tasks where occupational exposure may occur and at least annually thereafter. The annual training will occur prior to the anniversary date of the previous year's training. When modifications of tasks or procedures occur after the training period, the supervisor shall provide or arrange for any additional necessary training. When necessary, the training program will be modified to accommodate the educational level or language of the employee.


Medical Records. Human Resources will establish a file for each employee identified in the exposure determination. This file will include the following:

  • Employee name
  • Employee social security number or Drury University identification number
  • Hepatitis B Immunization Recommendation form with dates of injections and
  • Post exposure forms, if employee has had an exposure

Files related to employee exposure will be kept confidential and information in these files will not be disclosed or reported without the employee's written consent except as required by law. These records will be maintained for the duration of employment plus 30 years.

Medical records or laboratory studies obtained for past exposures will be maintained by the practitioner or agency administering the care.

Sharps Log.   A sharps log will be maintained to record the following: type and brand of device involved in a stick, department/work area where incident occurred and explanation of incident. The sharps log will be maintained for 5 years.

Training records. Documentation of attendance at a training class will include the date of the session, the content, and the names and positions of the trainers. Departments will be responsible for maintaining documentation of their employees training for three years from the date of the training session. The safety manager will also maintain copies of the training class record for classes conducted by safety manager staff.

Documentation of training records may be made available to employees or their representatives upon request.

Bloodborne Pathogens Decontamination Procedures

Blood, and other potentially infectious materials including hypodermic needles, must be handled by designated employees in the bloodborne pathogens program. In the event that any of the above is found by an employee not designated under the bloodborne pathogens program, those employees must contact either immediate supervisor or Facilities Services.

Trained personnel will clean up blood or other potentially infectious materials when they respond to a medical, fire, or security emergency.  

If hypodermic needles are found on campus, the following procedures will be followed:

•  Secure the area to assure that no one can be injured by the needle.
•  Call Safety Director to arrange for a sharps container and pick up the needle.
•  Safety Director will place the needle in the sharps container and close the container.
•  Sharps container will be returned to central location, e.g. supervisor's office.
•  A replacement sharps container can be obtained through the supervisor. (Sharps containers can also be purchased through Science Stores.)

When blood clean up is necessary, the following procedures will be followed by the trained individuals:

•  Secure the areas to assure that no one is exposed to the blood, while the designated person and supplies arrive.
•  Don appropriate personal protective equipment and lay out clean up materials that will be needed (garbage bag, tear off paper towels, set out disinfectant).
•  Spray area with disinfectant and begin wiping up with paper a towel, working inward to assure that the area is minimized, not enlarged.
•  Place soiled paper towels in garbage bag.
•  If necessary, repeat, assuring that outside of disinfecting container is not contaminated.

•  Take off gloves in manner that you don not touch the outside of the glove.

•  Place gloves in a garbage bag, and handling bag from the outside, tie bag.

•  If any of the material in the bag is dripping with blood or other potentially infectious material (not the disinfectant), double bag the material and place in supervisor's office and call Safety Director for pickup. If the material is not dripping with blood or other potentially infectious material (not the disinfectant), place in the regular trash.

Hepatitis B Vaccination Waiver