In December 1991, OSHA published the final rule covering occupational exposure to bloodborne pathogens. The rule requires that those who handle human blood or other potentially infectious (human) materials as part of their job duties participate in an employer-generated program. This program shall include development and annual review of the Exposure Control Plan, annual training regarding exposures, offer of hepatitis B vaccinations free-of-charge, and post-exposure health care services.
The Office of Environmental & Regulatory Compliance (ERC) manages this program. In addition to the program materials, ERC provides training sessions annually.
Hepatitis B vaccinations are given by the Student Health Care Center at no cost to the employee.
This Bloodborne Pathogens Policy has been developed by The Office of Environmental and Regulatory Compliance (ERC) as part of the Florida Tech’s Bloodborne Pathogens Program. Florida Tech’s Bloodborne Pathogens Program has been developed to ensure that all employees are protected from the risk of exposure to bloodborne pathogens, such as the Human Immunodeficiency Virus (HIV) and the Hepatitis B Virus (HBV). Florida Tech’s Bloodborne Pathogens Policy has been developed in accordance with the regulations set forth in the Occupational Safety and Health Administration's (OSHA), 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens Standard.
This policy will be applicable to all employees, students, and researchers who could be "reasonably anticipated", as the result of performing their job duties, to come in contact with blood and other potentially infectious materials.
Appendix A: Florida Institute of Technology Emergency Procedures
Appendix B: Forms
Appendix C: Florida Tech’s Exposure Control Plan
Appendix D: Definitions
Florida Tech is committed to providing a safe and healthful learning and work environment for all employees, students, and visitors. In pursuit, the following Exposure Control Plan (ECP) is prepared to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA Bloodborne Pathogens Standard, Title 29 Code of Federal Regulations 1910.1030.
The ECP is a key document to assist our University in the protection against infectious diseases. The implementation ensures compliance with the OSHA standard. All employees and students should therefore be familiar with the ECP and carefully follow the procedures and work practices as outlined.
The term “universal precautions” is a term used to identify an approach to infection control that effectively assumes all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV and other bloodborne pathogens.
All body fluids and other potentially infectious material previously mentioned are to be treated as infectious material and universal precautions shall be used as protection against contamination and appropriate precautions will be taken (i.e., donning protective gloves).
Florida Tech’s Exposure Control Plan (ECP) is a written program that outlines the protective measures that will be implemented to eliminate or minimize employee exposure to blood and other potentially infectious materials (OPIM). Employees covered by the bloodborne pathogens standard receive an explanation of this Bloodborne Pathogen Exposure Control Program during their initial training session. It will also be reviewed in their annual refresher training. All employees can review this plan at any time during their work shifts by contacting The Office of Environmental and Regulatory Compliance. If requested, a copy of the Bloodborne Pathogen Exposure Control Program will be provided to the employee free of charge within 15 days of the request.
All Florida Tech personnel affected by this plan will employ universal precautions when required by the given situation.
Only trained employees shall respond to an incident involving blood or and other potentially infectious materials.
The Office of Environmental and Regulatory Compliance (ERC) will review the ECP and update it on a regular basis. In that case, the plan will be assessed and updated immediately to accommodate workplace changes. The Office of ERC will also be responsible for:
An exposure incident is defined as an incident where mucous membranes (i.e., eyes, mouth) or abraded skin contact or subcutaneous injection has occurred with blood and other potentially infectious materials that has resulted from the performance of the employee's duties.
In the event of an exposure incident, the affected employee must immediately seek medical attention. The employee's supervisor should be notified as soon as possible (within the shift). The employee’s supervisor should complete an Accident/Injury Report (included in Appendix B of this section). The completed Accident/Injury Report should be turned to the Office of Environmental and Regulatory Compliance and a copy should be taken to the Holzer Student Health Center during normal business hours. For after-hours please send the completed form and the employee to Holmes Regional Hospital. The Office of ERC will review the form and conduct an investigation if necessary, and will make recommendations as to how to avoid future events.
All exposure incidents shall be reported, investigated, and documented. When the employee incurs an exposure incident, it shall be reported immediately to their supervisor.
If an exposure incident has occurred, then the employee will also be immediately provided with a post-exposure evaluation and follow-up, by a Licensed Healthcare Professional, as set forth in 29 CFR 1910.1030(f)(3), which includes testing of the source individual as soon as possible, if consent of the source individual is obtained. If consent is not obtained, Florida Tech shall establish in writing that legally-required consent cannot be obtained.
Following a report of an exposure incident, the exposed employee shall go to the Hozler Student Health Center at Florida Tech (during business hours 8am-8pm Monday through Thursday, 8am to 5pm Friday) and the Holmes Regional Hospital (if it is after hours or during weekend) for a confidential medical evaluation and follow-up, including at least the following elements:
The employee will receive 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 for Hepatitis B vaccination is limited to the following: (1) whether the employee needs Hepatitis B vaccination; (2) whether the employee has received such a vaccination. The healthcare professional's written opinion for post-exposure evaluation and follow-up is limited to the following information:
All other findings or diagnoses will remain confidential and will not be in a written report. All medical evaluations shall be made by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional. All laboratory tests must be conducted by an accredited laboratory at no cost to the employee. All medical records will be kept in accordance with 29 CFR 1910.1020.
Hepatitis B Virus (HBV) causes an infection of the liver. Symptoms of HBV infection may range from none to flu-like symptoms, jaundice and serious illness. If symptoms do occur, they may not be evident until 2 to 6 months after the person is infected. Infection with HBV can lead to chronic diseases later in life, such as cirrhosis and liver cancer and death.
Hepatitis B can be transmitted in many of the same ways as HIV - parenteral and mucous membrane exposures to infected body fluids.
The best way to prevent HBV infection is:
All Florida Tech employees, who have the potential for occupational exposure to blood or OPIM, will be offered the Hepatitis B vaccination series within 10 working days of assignment, at no cost. These vaccinations will be administered by OMNI Healthcare at Florida Tech. The vaccinations will be administered under the supervision of a licensed physician/licensed healthcare professional. If any Florida Tech employee renders first aid to a person which involves the presence of blood or other potentially infectious material, regardless of whether an “exposure incident” occurred, then the HBV vaccination will be made available to the employee within 24 hours of the incident in accordance with 29 CFR 1910.1030(f)(2).
If the Florida Tech employee declines the HBV vaccine following an event that would warrant the HBV vaccine to be administered, the employee must complete the “Hepatitis B Vaccination Acceptance/ Declination Form” included in Appendix B of this Plan.
All hepatitis B vaccinations will be provided by OMNI Healthcare at Florida Tech. All identified employees will receive the Hepatitis B Vaccination Acceptance/ Declination Form (see Appendix B). If the employee elects to receive the vaccinations he/she will return the completed form to their departmental office. The departmental office will notify The Office of Environmental and Regulatory Compliance of how many people have elected to receive the vaccinations and will notify OMNI Healthcare at Florida Tech.
Upon receiving the first of three vaccinations, OMNI Healthcare at Florida Tech will issue a form, which will remind the employee of the next vaccination.
Upon completing all three vaccinations, the employee will keep a copy of the completed vaccination from. In addition, the departmental office of Environmental and Regulatory Office will also receive and maintain copies of the completed vaccination forms.
All aspects of the Florida Tech’s Hazard Communication Program will be implemented when handling blood or OPIM. This will include the proper use of labels and employee awareness training. Employees will be trained to recognize potential exposure situations and how to protect themselves through the proper use of engineering controls and Personal Protective Equipment. The red Bio-hazard bags will be used to store or transport materials contaminated with blood and other potentially infectious materials.
Warning labels that include the universal Bio-hazard/ Biomedical waste symbol, followed by the term “Bio-hazard Waste/ Biomedical Waste," will be included on bags/ containers of contaminated laundry, on bags/containers of Bio-hazard waste, bags/containers used to dispose, transport blood or OPIM. In addition, contaminated equipment which is to be serviced or shipped will have a readily observable label attached which contains the Bio-hazard/ biomedical waste symbol and the word " Bio-hazard /biomedical" along with a statement relating which portions of the equipment remain contaminated. Please refer to Florida Tech’s Biomedical waste Management Plan for additional information.
All employees, students, and affiliates at risk of exposure to bloodborne pathogens must participate in annual bloodborne pathogen training. All employees receiving bloodborne pathogens training will be trained in the following items. The training may be performed in conjunction with first aid training:
Florida Tech will ensure that training of affected personnel will be provided at no cost to the employee during normal working hours. Training will be provided prior to initial assignment as a first aid and CPR responder and where anticipated employee occupational exposure may take place and annually thereafter. Training contents are to be in accordance with 29 CFR 1910.1030(g) (2). BBP Trainings are conducted through the Office of Environmental and Regulatory Compliance.
All medical records regarding occupational exposures will be kept on file in the ERC office. These files will be kept for each employee and will be maintained for the duration of employment plus 30 years. In addition, all records will remain confidential and will include the employees name and I.D.#; 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 healthcare professional. All training records will be maintained for three years and will include the dates of training, contents of the training program, trainer's name and qualifications, names and job titles of all persons attending the sessions. All training records will be kept on file in the ERC office. All records to be maintained shall be made available upon request to anyone as required or permitted by law. These records also will be provided upon request for examination and copying to the subject employee or to anyone having written consent of subject employees.
Any occupational exposure requiring medical treatment (i.e., gamma globulin, Hepatitis B immune globulin or Hepatitis B vaccination, etc.) shall be recorded on the OSHA 300 and 300A logs if:
However, due to privacy concerns, “privacy case” must be entered in the space normally used for the employee’s name. A separate, confidential list of the case numbers and employee names for the privacy concern must be maintained in case the information is requested by authorized government agencies.
During business hours 8am- 5pm for all non-life threatening emergencies first call facilities at x 8038(on campus) 321-674-8038 (off campus) and campus security at x 8111 (On Campus) 321-674-8111 (Off Campus). For after hour incidents, please contact security at x 8111 (On Campus) 321-674-8111 (Off Campus)
For ambulance call 911 or 9-911 then call campus Security.
Universal precautions will be observed by all employees in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious materials 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 employees working at Florida Tech University.
i) Needles and sharps should never be recapped.
ii) Needles, sharps and broken glass may be moved or picked up only by using a mechanical device or tool (forceps, pliers, broom and dust pan).
iii) Breaking or shearing of needles and sharps are prohibited.
iv) No eating, drinking, applying cosmetics or lip balm, or handling contact lenses is allowed in a work area where there is a reasonable likelihood of occupational exposure.
v) Employees must perform all procedures involving blood or other potentially infectious materials in such a manner as to minimize splashing, spraying, splattering, and generation of droplets of these substances.
Decontamination will be accomplished by utilizing the following materials:
a) 10% (minimum) solution of chlorine bleach
b) Lysol or other EPA-registered disinfectants
Personal Protective Equipment (PPE) will be utilized as a barrier between the employee and blood or OPIM. The proper use of PPE is an important component of the universal precautions procedures. Please use the cleanup kit in your Department when cleaning blood or OPIM. All of these safety items will be replaced as necessary to ensure an adequate supply is always on hand.
All contaminated sharps shall be disposed of in red sharps containers. These containers will be supplied by the ERC office upon request. The ERC waste handlers routinely perform lab inspection and waste removal. All disposals of sharps and other bag waste will be coordinated through ERC.
Nitrile or hypo allergic gloves will be provided whenever an employee must handle blood or OPIM contaminated material. All gloves used shall be disposed immediately after use. These gloves will not be washed or disinfected for reuse.
Employees will not be permitted to take their protective equipment home and launder it. It is the responsibility of the employer to provide, launder, repair, replace, and dispose of personal protective equipment.
All gloves should be examined prior to use for cuts, tears, or punctures. To prevent exposure of mucous membranes of the mouth, nose and eyes, masks and protective eyewear (i.e. safety glasses or goggles) shall be worn for procedures that are likely to generate droplets or splashes of blood or OPIM.
Florida Tech’s policy is to use only Nitrile or hypo allergic gloves. Latex gloves have proved effective in preventing transmission of many infectious diseases. But for some workers, exposures to latex may result in allergic reactions. Reports of such reactions have increased in recent years.
All Florida Tech employees will take precautions to prevent injuries by needles, scalpels, knives and other sharp instruments or devices. To prevent needlestick injuries, contaminated needles shall not be recapped, purposely bent or broken by hand, removed from disposable syringes, or otherwise manipulated by hand.
After they are used, disposable syringes and needles, scalpel blades, and other sharp items shall be placed in the provided sharps containers.
When emptying trash receptacles the following procedures should be implemented to reduce injuries:
If there is a spill of human blood or OPIM, the spill situation must be addressed immediately. The ERC office should be notified immediately. If the appropriate PPE and spill cleanup materials are present, and the employee has received the Bloodborne Pathogens training, he or she may contain and clean up the spill if it will not jeopardize his or her health or those in areas of close proximity.
Any sharps material involved in the spill (i.e. broken glass, Kitchen utensils, syringes, etc), shall be carefully removed. Sharps will be placed in a sharps container. Once the sharps materials have been removed, the spill will be cleaned up. The spill area shall be washed thoroughly with a fresh made bleach solution or other appropriate disinfectant.
Any equipment used to clean up spills (i.e mops, etc) must be either decontaminated with the appropriate germicide or disposed of properly Sharps Containers.
Sharps Containers provided will be:
Each sharps container will be labeled with the universal biomedical symbol and the word "biomedical", or be red in color. Sharps containers shall be maintained upright throughout use, replaced routinely, and not be allowed to overfill when removing sharps containers from the area of use, the containers shall be:
Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of percutaneous injury.
Sharps containers will be made easily accessible to employees and located as close as possible to the immediate area where sharps are used or can be reasonably anticipated to be found.
All areas which contain biomedical wastes agents must be labeled with a biomedical waste warning label. The symbol will be red, orange, or black and the background color shall contrast with that of the symbol or comply with the regulations of the Occupational Exposure to Bloodborne pathogen Standard. The label shall be securely or permanently printed on each bag and sharps container and be clearly legible.
ERC office will coordinate the disposal of all biomedical waste in accordance with applicable regulations of the United States.
Blood - Defined as human blood, human blood components, and products made from human blood.
Bloodborne Pathogens - Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and the Human Immunodeficiency Virus (HIV).
Contamination - Contamination refers to the presence or reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
Contaminated sharps - Any contaminated object that can penetrate the skin including, but not limited to needles, scalpels, broken glass, broken capillary tubes, knives, kitchen utensils and plastic ware.
Decontamination - The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item. As a result, the surface or item is no longer capable of transmitting infectious particles and the surface is rendered safe for handling, use or disposal.
Engineering Controls - Mechanical devices that isolate or remove the bloodborne pathogens hazard from the workplace. Includes sharps containers, shielding, or self-sheathing needles.
Good Samaritan Acts - Good Samaritan acts, such as helping a fellow worker with a nosebleed or cut finger, are not considered official duties or exposures covered under this plan.
Occupational Exposure - Defined as "reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of the employee's duties."
Other Potentially Infectious Materials (OPIM) - Defined as the following human body fluids: body fluids visibly contaminated with blood; along with all body fluids in situations where it is difficult or impossible to differentiate between body fluids; unfixed human tissues or organs (other than intact skin); HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV- containing culture media or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Parenteral - Piercing of mucous membranes or the skin through such events as: needlesticks, human bites, cuts, and abrasions.
Spill Cleanup kit contains: Gown, Gloves, Mask, Kitty Litter, whiskbroom, Paper towels, Dustpan, Household bleach/ Chemical Germicide, Biomedical Waste Red Bags/ sharps Container ( as applicable)
Biomedical Waste - refers to the following categories of waste which require special handling at a minimum; (1) liquid or semiliquid blood or OPIM; (2) items contaminated with blood or OPIM and which would release these substances in a liquid or semi-liquid state if compressed; (3) items that are caked with dried blood or OPIM and are capable of releasing these materials during handling; (4) contaminated sharps; and (5) pathological and microbiological wastes containing blood or OPIM.
Standard Precautions - An approach to infection control. According to the concept of Standard Precautions, all human blood and all human body fluids are treated as if infectious. Formerly referred to as Universal Precautions.