Environmental Health & Safety
In Compliance with 29 CFR 1910.1030 OSHA Standard for Occupational Exposure to Bloodborne Pathogens
Bloodborne Pathogens Exposure Control Plan
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- PROCEDURES
- Hepatitis B Vaccination
- The hepatitis B vaccination series is recommended for all personnel at risk of occupational exposure to human blood or other potentially infectious materials.
- The University provides vaccination at no cost to employees identified in the exposure determination section of this plan. Department/Units included in this vaccine program are determined by the University Administration based on recommendations from Environmental Health & Safety, Occupational Health and Infection Prevention Programs. Other requirements of the vaccination program include:
- The first vaccination shall be made available to all eligible employees within 10 working days of initial assignment.
- Employees who decline the hepatitis B vaccination at the time it is offered will be required to sign a statement explaining that they understand the risks associated with acquiring hepatitis B virus infection, that they were offered the vaccination at no charge, and that if they change their mind in the future they can then receive the vaccination.
- If an employee initially declines hepatitis B vaccination but at a later date (while still covered under the standard) decides to accept the vaccination, the employer shall make available hepatitis B vaccination at that time at no cost to the employee.
- If a routine booster dose(s) of hepatitis B vaccine is recommended by the United States Public Health Service at a future date, such booster doses(s) shall be made available to employees with continued occupational exposures at no cost to the employees.
- Vaccine Preparation - Recombinant hepatitis B vaccine
- Vaccine Administration - Vaccine is given in the deltoid muscle in a series of 3 injections (initial, 1 month, 6 months).
- Pre-vaccination serologic screening is not routinely performed. If an employee wishes to be screened prior to vaccination, he/she may do so at his/her own expense.
- Post-vaccination screening and revaccination as per University of Rochester Medical Center/Strong Memorial Hospital Bloodborne Pathogens Protocol
- Post-vaccination screening (anti-HBs = Hepatitis B surface antibody) is performed 1-2 months after the third dose of vaccine. Vaccine non-responders (negative anti-HBs) will be revaccinated followed by anti-HBs screening.
- Employees previously vaccinated, but never screened for anti-HBs, may be screened at a later time and revaccinated if necessary (negative anti-HBs).
- Routine periodic screening and/or revaccination is not presently recommended by the United States Public Health Service, except as part of exposure follow-up.
- Vaccinees who request periodic screening and/or revaccination, except as specified above, may do so at their own expense.
- Labels
- Labels shall include the following legend:
- Labels shall be fluorescent orange or orange-red with lettering or symbols in a contrasting color.
- Red bags or red containers may be substituted for labels.
- Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirements.
- Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.
- Equipment which is contaminated shall be labeled and labels shall state what parts of equipment cannot be decontaminated.
- Training
- Employees identified in the exposure determination as having occupational exposures shall participate in a training program which shall be provided at no cost to the employee and during working hours.
- Training will be provided for all current employees identified at time of exposure determination. New employees will be trained at the time of initial assignment to tasks where occupational exposure may take place.
- Annual training for all employees shall be provided within one year of their previous training. This is included in the annual Mandatory In-Service Education Program.
- Additional training shall be provided when changes such as modification of tasks or procedures or institution of new tasks or procedures affect the employee's occupational exposure. The additional training may be limited to addressing the new exposures created.
- Trainers will be knowledgeable in the subjects of bloodborne pathogens, PPE, the content of this Exposure Control Plan, and the requirements of the OSHA standard. Trainers will have experience in infection control, occupational health, industrial hygiene, or nursing.
- The training program shall contain the following elements:
- An accessible copy of the regulatory text of this standard and an explanation of its contents.
- A general explanation of the epidemiology and symptoms of bloodborne diseases.
- An explanation of the modes of transmission of bloodborne pathogens.
- An explanation of this Exposure Control Plan and the means by which the employee can obtain a copy of the written plan.
- An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
- An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment (PPE).
- Information on the types, proper use, location, removal, handling, decontamination, and disposal of PPE.
- An explanation of the basis for selection of PPE.
- Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered at no charge.
- Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
- An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
- Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident.
- An explanation of the signs and labels and/or color-coding.
- An opportunity for interactive questions and answers with the person conducting the training session.
Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material, and other containers used to store, transport or ship blood or other potentially infectious materials. (In the hospital and in the clinical areas of Eastman Institute for Oral Health where Universal Precautions are utilized extensively in the handling of all specimens, the labeling/color-coding of specimens is not necessary provided that containers are recognizable as containing specimens. If the specimens are to be sent to an outside agency they must bear the biohazard symbol or red coloring. See Specimen containers and transport for further information.)
Continue to Section V, Part K - Recordkeeping
QUESTIONS? Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.
This page last updated 7/22/2025. Disclaimer
