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Revised: January 2023

Introduction to the Bloodborne Pathogens Exposure Control Plan

The University of ÁùºÏ±¦µä, Reno Bloodborne Pathogens Exposure Control Plan incorporates the most current work procedures, engineering controls, and medical surveillance practices. The Institutional Biosafety Committee has reviewed and approved the Plan and fully endorses its implementation. This latest revision of the Bloodborne Pathogen Exposure Control Plan replaces in its entirety the earlier revision dated January 2022.

The Bloodborne Pathogens Exposure Control Plan is designed to minimize risks to the University community from exposure to human blood, blood products, and other potentially infectious materials, and to meet regulatory expectations mandated by the Occupational Safety and Health Administration (OSHA). The Bloodborne Pathogens Exposure Control Plan is the document that describes the institutional University Bloodborne Pathogens Program that is administered by the Environmental Health and Safety Department (EH&S).

University supervisors who have oversight of personnel who are potentially exposed to bloodborne pathogens as part of their occupational duties are expected to comply with the requirements of the University Bloodborne Pathogens Program. Personnel that work with, or may reasonably have contact with, human blood, body fluids, unfixed tissue, and human tissue culture or cell lines are considered to be at risk from bloodborne pathogens. Each department or supervisor is required to identify these individuals and comply with the elements of the University Bloodborne Pathogens Program, including hepatitis B vaccination and annual training.

The job activities and scenarios that fall under the purview of the Bloodborne Pathogens Exposure Control Plan are broad, and it is strongly recommended that each administrative unit review the Plan for applicability. In addition to this online version, hard copies are available from the Environmental Health & Safety Department (EH&S).

The Institutional Biosafety Committee believes that the Bloodborne Pathogens Exposure Control Plan supports the University’s goal of ensuring a safe and healthy learning, research, work, entertainment, and living environment for students, staff, faculty, and visitors. The Institutional Biosafety Committee strongly encourages each department and supervisor to fully adopt the Bloodborne Pathogens Exposure Control Plan and implement its requirements as applicable.

The enclosed document comprises the Bloodborne Pathogens Exposure Control Plan for the University of ÁùºÏ±¦µä, Reno, as required by State regulations and Federal OSHA Statute 29 CFR 1910.1030, hereafter referred to as the Plan. By design, it is broad in both scope and content.

Due to extreme diversity in organization, procedures, and functions between each of the different departments, schools, and campuses that constitute the University of ÁùºÏ±¦µä, Reno, it is not possible to draft a single policy that adequately covers all requirements of the standard. Therefore, it is necessary for each department, school or campus to complete certain portions of the plan that will be unique to that entity. Those portions of the plan are:

1. Occupational Exposure Assessment – Supervisors must classify all employees into one of two groups by level of exposure risk associated with their occupational tasks.
   1. The high exposure potential group includes all employees that work with, or have potential exposure to blood, blood products, or other potentially infectious materials (OPIM)* while performing their assigned job duties. This group must be included in the bloodborne pathogens training program.
   2. The low exposure potential group includes employees not at risk for exposure to bloodborne pathogens. Examples of employees typically included in this group are office workers, data entry personnel, non- laboratory professors, and anyone who is not exposed to blood or other potentially infectious human or animal materials as part of their normal work duties.
2. Engineering Controls - All necessary engineering controls must be available in the workplace and maintained or replaced on a regular schedule to ensure their effectiveness. As stated in Section K of Methods in the Plan, each department that utilizes sharps for patient healthcare purposes must form a committee to evaluate sharps engineering controls.
3. Containerization and Labeling - Container and label requirements are detailed under appropriate headings in the Plan. Each supervisor is required to ensure that all employees are familiar with, and understand, the specific labeling requirements established within their workplace.
4. Personal Protective Equipment - Appropriate personal protective equipment must be identified for tasks that are considered to present a risk of exposure and must be provided to employees at no cost to them
5. Cleaning Schedules - Work surfaces must be decontaminated using a bleach solution (1/10 dilution of household bleach prepared within the past 24 hours) or an that is registered as a sterilizer (List A), effective against Mycobacterium tuberculosis (Lists B and E), or effective against HIV 1 and HBV (Lists D and E) as soon as possible after a spill of blood or OPIM, and at the completion of the work schedule.
6. Sharps Containers – Containers must remain closed unless waste is actively being added. When containers are approximately three-fourths full, a request for pickup by EH&S should be submitted. Containers are available free of charge from EH&S by request through the EH&S website Additional information is available in the University Biosafety Manual (see Chapter 13, Biohazardous Waste).
7. Hepatitis B Virus (HBV) Vaccination and Post Exposure Evaluation Follow up – HBV vaccination will be offered to everyone who has a potential exposure and post exposure medical evaluation must be provided in accordance with OSHA requirements. The specific requirements for each, along with record keeping requirements, are outlined in the Plan.
8. Employee Training - Both initial Bloodborne pathogens and annual refresher training are required for all employees who are occupationally exposed to either blood or other potentially infectious material. Both the initial and annual refresher versions must include protective measures to be taken to prevent exposure to bloodborne pathogens. Retraining is required should changes in procedures or tasks occur. Further details of the training requirements are contained in the appropriate section of the Plan.
9. Record Keeping - Records of training conducted by EH&S are maintained by EH&S. These records include the class roster, training presentation slides, and vaccination declination/acceptance forms. The University Workers’ Compensation Office keeps records of exposure incidents involving bloodborne pathogens including associated medical records

*NOTE: Other potentially infectious materials (OPIM) include:

• semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visibly contaminated with blood, and anytime it is difficult to differentiate between body fluids;
• any unfixed tissue or organ (other than intact skin) from a human (alive or dead);
• human cell or tissue cultures, organ cultures; HIV-containing culture medium, tissue culture, solutions, blood, organs, or tissue from experimental animals infected with HIV, HCV or HBV.
• research animals into which human cells have been introduced may be considered to be a source of OPIM, as determined by the University Institutional Biosafety Committee on a case by case basis.

Questions regarding this Plan, or requests for assistance in implementing Plan requirements should be directed to the University of ÁùºÏ±¦µä, Reno, Environmental Health & Safety Department at (775) 327-5040.

Scope

This safety policy is directed towards protecting, as much as possible, all University personnel from exposure to blood and OPIM. It is designed to achieve compliance with State and Federal Occupational Health and Safety Administration (OSHA) standards, specifically 29 CFR 1910.1030,

Student Health maintains its program consistent with this document and has additional requirements consistent with its clinical mission.

Applicable Documents

CFR Title 29 1910.1030,

Methods

A: Exposure Determination

The following conditions should be considered as constituting a potential exposure:

1. Any needlestick with used or contaminated equipment.
2. Any cut or other puncture of the skin caused by contaminated equipment, tools, scalpels, etc.
3. Any exposure of blood or other potentially infectious material (OPIM) with mucous membranes, such as contact to the mouth, eye, nostril, etc.
4. Any cutaneous exposure involving large amounts of blood or OPIM or prolonged contact, especially when the exposed skin is chapped, abraded, or afflicted with dermatitis.

Any incident meeting the above detailed criteria requires appropriate first aid, and reporting to the immediate supervisor of the exposed personnel, the Environmental Health and Safety Department, and the Workers ’ Compensation Office at Business Center North (BCN).

An exposure determination of University job classifications is provided in Appendix A. This exposure determination lists job classifications in which all employees have occupational exposure to bloodborne pathogens, and job classifications in which some employees have occupational exposure.

B: Control Methods

University personnel will use four methods, either singly or in combination, to control occupational exposures to bloodborne pathogens. These methods are:

1. universal precautions
2. engineering controls
3. established work procedures
4. personal protective equipment.

1: Universal Precautions

Under normal circumstances, an individual does not know if a patient or a laboratory sample contains a bloodborne pathogen. In view of the above, the Centers for Disease Control and Prevention (CDC) recommends that all human blood and OPIM be considered infectious unless the source is known with certainty to be non- infectious. This is particularly true in emergency care situations where the risk of exposure is increased and little or nothing is known about the infection status of the injured individual. These universal precautions are categorized as follows (see Appendix B):

1. General Guidelines (all health care workers)
2. Precautions for Laboratories

2: Engineering Controls

These controls must be employed in order to minimize exposures to workers while performing their job duties. This includes engineering controls used to prevent needlestick injuries. Any device or procedure that requires the use of a needle must be engineered using the best available technology. Preferably a needle is not used to perform the task, but if use of a needle is necessary, then the operator must be protected from a potential needlestick injury.

1. Engineering controls to be used include, but might not be limited to, the following:
   1. Self – sheathing needles
   2. Jet injection devices
   3. Catheter safety systems
   4. Needleless systems
   5. Appropriate sharps containers (available from EH&S)
   6. Splash guards
   7. Mechanical pipetting devices
   8. Biological safety cabinets (BSC)
   9. Washing facilities
2. Equipment shall be examined on a regular schedule determined by the manufacturer’s recommendations or University policies. Equipment shall be evaluated on a regular basis and when applicable, results will be forwarded to the responsible supervisor such as the clinic manager, head nurse, or principal investigator. These findings are to be used to determine efficacy of equipment as well as service or maintenance requirements. The responsible supervisor is designated as being responsible for ensuring completion of these activities.

3: Established Work Procedures

This method utilizes “best practice” work procedures, such as listed below, to eliminate or minimize the occupational exposure potential to the employee.

1. Remove PPE:
   1. Before leaving the work or research area
   2. Immediately after completing patient contact
   3. If PPE is grossly contaminated
   4. If PPE no longer works as an effective barrier
2. Place soiled or used equipment in appropriately designated containers or areas for storage, washing, decontamination, or disposal.
3. Use water to thoroughly flush the skin or mucous membranes as soon as possible if they come into contact with blood or other potentially infectious materials. Personnel will wash hands as soon as possible after removal of gloves or other PPE.
4. When needles or other sharps are used, the best available engineering controls that are compatible with the procedure to be performed must be in place to avoid a laceration or needlestick incident. Do not shear, bend, break, recap or resheathe used needles and other sharps by hand. For reusable syringes, a recapping method that prevents accidental needlesticks shall be used (e.g., mechanical device or one-handed technique).
5. All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing and spraying.
6. Conduct procedures expected to produce significant aerosols of BBPs in a biological safety cabinet or other primary containment device.
7. Use a pipet bulb or aspirator for pipetting, NEVER pipet by mouth.
8. Food, gum, beverages, cosmetics, lip balm, etc. shall not be consumed, stored, or applied in work areas where the possibility of contamination by infectious materials exists. Similarly, do not handle contact lenses in these areas. Additionally, smoking and vaping are prohibited in laboratory areas.
9. Work surfaces must be decontaminated using a bleach solution (1/10 dilution of household bleach prepared within the past 24 hours) or an that is registered as: a sterilizer (List A), effective against Mycobacterium tuberculosis (List B and E), or effective against HIV 1 and HBV (List D and E) as soon as possible after a spill of blood or OPIM, and at the completion of the work schedule.

4: Personal Protective Equipment

Personal protective equipment (PPE), such as gloves and lab coats, is specialized equipment or clothing worn by workers that provides an effective barrier to blood or OPIM. The supervisor is responsible for providing all affected staff members with necessary PPE. The supervisor must conduct employee PPE assessments and implement these assessments in the workplace standard operating procedures (SOPs). PPE is not to be considered a substitute for proper work procedures. PPE can include, but is not limited to those listed below in Table I. Required PPE can be modified following an assessment of the risk of any specific procedure.

Medical Students, Physician Assistant Students, Resident and Attending physicians carrying out duties at non-University hospitals and clinics are required to follow the host institution's exposure control plan with respect to PPE use.

Table I: Possible hazards and corresponding personal protective equipment

Hazard	Eye	Face	Hand/Body
Any use of chemicals	Safety glasses; goggles when high likelihood of spray or splash	Face shield and goggles for large liquid volumes (≥4 L)	Lab coat and gloves as recommended in the University Chemical Hygiene Plan (CHP)
Clinical functions where there is the potential for splash of BBPs.	Safety glasses	Face shield when there is high likelihood of spray or splash	Lab coat or gown, gloves
Biomedical research and clinical laboratory work involving BBPs	Safety glasses; goggles when high likelihood of spray or splash	Face shield for large volumes or high likelihood of spray or splash	Lab coat, gloves
Use of carcinogens, reproductive toxins, and other highly toxic compounds	Safety glasses; goggles when high likelihood of spray or splash	Face shield and chemical goggles for large liquid volumes (≥4 L)	Lab coat and gloves as recommended in the University CHP
Cryogenic liquids	Goggles	Face shield and chemical goggles when pouring or other transfers	Lab coat, cryogenic gloves or other insulated gloves that provide cold protection, solid toe shoes
Surgery or Containment: animal facilities or biosafety level 3 laboratories	Safety Glasses	Face Shield if spray or splash hazard Respirator: as prescribed by work-specific SOP	Gown, shoe covers, gloves, or as prescribed in laboratory SOP

C: HBV Vaccination

1. Vaccination against the hepatitis B virus must be offered, under the direction of a health care provider, under the following conditions to all employees and declared volunteers whose listed job responsibilities involve contact with blood or other potentially infectious materials:
   1. HBV vaccination is paid for by the employer and provided at no cost to the employee.
   2. The vaccination shall be offered to employees at a reasonable time and place.
   3. It shall be made available within ten working days of employee's original assignment to the position.
   4. Valid information about the vaccine must be given to the employee so that an informed decision can be made about the effectiveness of the vaccine.
   5. Employees in high risk environments such as clinicians, nurses, or phlebotomists will be offered testing for antibody to hepatitis B surface antigen (HBsAg) one to two months after completing the three dose vaccination series. Persons who do not respond to the primary vaccine series should complete a second three dose vaccine series or be evaluated to determine if they are HBsAg positive.
   6. Employees, whose job tasks involve contact with blood or OPIM, who decline to accept the vaccination, shall sign a statement declaring their refusal (see Appendix D. Should an employee later change his or her mind, the vaccination shall be made available to him or her under the above detailed conditions.
   7. Vaccinations for all University employees, including student workers are administered through the Occupational Health Clinic.
      
      

      Renown Health Urgent Care - Ryland
      975 Ryland St.
      Reno, NV 89502
      (775) 982-5000

2. Employers are only required to provide vaccination to employees who are considered at risk to exposure due to job requirements.

D: Post Exposure Evaluation and Follow-up

1. In the event of an exposure incident, as defined in the Exposure Determination section of this Plan, the affected employee shall receive immediate first aid to mitigate effects of possible exposure. First aid for a possible exposure incident shall consist of the following procedures:
   1. Needlesticks with used or contaminated equipment
      1. Wash the area with soap and water
      2. Cover the wound with sterile bandage as needed
   2. Cuts or punctures of the skin caused by contaminated equipment, tools, scalpels, etc.:
      1. Wash the area with soap and water
      2. Use disinfectant on cuts if available
      3. Cover with sterile bandage as needed
   3. Mucous membrane exposure to blood or OPIM, such as a splash to the mouth, eye, etc.:
      1. Wash the area of possible exposure with running water
      2. Do not take the time to attempt removal of contacts before flushing eyes Allow contact lenses to be flushed out by running water If contact lenses are not flushed out then remove them after a thorough initial flush and then thoroughly re-flush the eyes.
   4. Cutaneous exposure involving large amounts of, or prolonged contact with, blood or OPIM especially when the exposed skin is chapped, abraded, or afflicted with dermatitis (1) Wash
      1. the affected area with soap and running water
      2. Use disinfectant on the affected area if available
2. After first aid treatment, the employee shall report the incident to his/her supervisor. In addition, the BCN Workers’ Compensation Office and the Environmental Health and Safety Department must be notified of the event. CDC recommendations state that prophylaxis is most effective when initiated within two hours of the incident; therefore, it is imperative that the employee go to one of the below listed medical facilities providing services for the Workers’ Compensation program as soon as possible. All employees, including student employees, must not use the Student Health Clinic for evaluation.
   

   Facilities located near the University that participate in the program are listed below. A list of Workers’ Compensation authorized urgent care and clinics is available on the BCN Workers’ Compensation Office website

   Urgent Care Facilities for injuries requiring a doctor’s attention during working hours:

   Reno

   Renown Health Urgent Care - Ryland (preferred)
   975 Ryland St.
   Reno, NV 89502
   (775) 982-5000
   Monday-Friday, 8 a.m.-5 p.m.

   Concentra Medical Centers
   6410 South Virginia Street
   Reno, NV 89511
   (775) 322-5757
   Hours: Monday-Friday, 8 a.m.-6 p.m.

   ARC Health & Wellness Centers
   2205 Glendale Avenue
   Suite 131
   Sparks, NV 89431
   (775) 331-3361
   Hours: Monday-Friday, 8 a.m.-5 p.m.

   ÁùºÏ±¦µä Occupational Health Clinic
   3488 Goni Road
   Suite 141
   Carson City, NV 89706
   (775) 887-5030
   Hours: Monday-Friday 7:30 a.m.-5 p.m.

   Emergency Rooms for life threatening injuries or treatment outside of Urgent Care facility business hours:

   Renown Regional Emergency Room
   1155 Mill St.
   Reno, NV 89502
   (775) 982-4100

   Las Vegas

   Concentra Medical Center
   3900 Paradise Rd., Suite V
   Las Vegas, NV 89169
   (702) 369-0560
   Monday-Friday, 7 a.m.-6 p.m.

   Concentra Medical Center
   5850 S. Polaris Rd., #100
   Las Vegas, NV 89118
   (702) 739-9957
   Open 24 hours, 7 days a week

3. The health care facility will provide a confidential medical evaluation to the employee The affected employee’s administrative department or group, in concert with EH&S as appropriate, will review the exposure incident. The following elements shall be performed during the evaluation:
   1. Document the route of exposure and circumstances of the incident. If a needlestick causes the incident, it must be also documented on a separate needlestick incident log. The University Workers’ Compensation Office handles needlestick documentation.
   2. Document the identity and infectious status of the source individual. If the infectious status is not established, the source individual's blood shall be tested as specified by State and local laws and regulations
   3. Notify the exposed employee of the source individual’s test results if these results are available.
   4. Collect and test the exposed employee's blood as soon as feasible after obtaining consent. If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If within 90 days of the exposure incident the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.
   5. Should prophylaxis be recommended, follow the for post exposure prophylaxis
   6. The employer shall 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
4. The healthcare professional responsible for evaluating the exposed employee will obtain as part of the evaluation:
   1. A copy of the OSHA Bloodborne Pathogen Standard, 29 CFR 1910.1030
   2. A description of the employee's duties related to the incident
   3. Documentation of the route of entry and exposure circumstances
   4. Available source blood testing results
   5. A copy of, or information regarding, all available medical records relevant to the treatment of the employee, including vaccination status which are the employer’s responsibility to maintain
5. The results of the medical evaluation are to be strictly confidential between the healthcare professional and employee. The exposed employee’s supervisor will obtain a written notice from the healthcare professional and provide a copy to the employee following completion of the medical evaluation. The notice will not contain any findings or diagnoses. The notice to the supervisor should contain the following:
   1. A statement that the employee has been notified of the evaluation results
   2. A statement that the employee has been notified of any medical conditions that may arise from the exposure which may require further treatment
6. All records must be kept in accordance with the Recordkeeping section of this Plan (Section J.2).

E: Infectious Waste Material

1. All biohazardous waste must be disposed of according to the procedures outlined in the University Biohazardous Waste Management Plan Management of biohazardous waste is governed by Washoe County Health Department regulations (see Appendix C).
2. Sharps, both contaminated and uncontaminated, must be collected in rigid, leak proof, puncture resistant containers that are properly labeled as biohazardous waste. Appropriate sharps containers can be obtained from EH&S and can be requested using the standard request forms on the EH&S website or call (775) 327-5041 if web access is unavailable.
3. Solid biohazardous waste must be collected in an approved autoclavable biohazard bag and autoclaved prior to disposal. Biohazard bags can be obtained from EH&S and can be requested using the standard request forms on the EH&S website or call (775) 327-5041 if web access is unavailable. Solid biohazardous waste should be autoclaved as soon as possible after the bag if full; however, biohazardous waste bags can be stored up to seven days if all storage requirements are met (see the University Biohazardous Waste Management Plan)

F: Biohazard Labels and Signs

1. Warning labels must be affixed to waste containers, refrigerators, freezers, and other containers used to store, transport or ship blood or OPIM. Labels shall:
   • Display the universal biohazard symbol and contain the word "biohazard"
   • Be predominantly fluorescent orange or orange-red, with lettering and symbols of contrasting color.

Examples of biohazard labels and signs:

1. 1. Be affixed as close as feasible to the container by string, wire, adhesive or other method that prevents their accidental loss
   2. Be optional if individual containers of blood or OPIM are placed in labeled containers
   3. Not be used on containers of blood or blood products that are labeled as to their contents and released for transfusion or other clinical uses
   4. Not be required for decontaminated waste
2. Laboratories that use human blood or OPIM, or bloodborne pathogens such as HIV and HBV shall post signs with the following:
   • Universal biohazard symbol with the word "biohazard" above or below it
   • Biosafety level and type of material worked with
   • Special requirements for entering the area
   • The name and telephone number of the lab director or other responsible person

G: Housekeeping Practices

1. Responsible/Supervisory personnel are obligated to maintain the work-site in a clean and sanitary condition. They shall establish and implement a written schedule for cleaning and appropriate decontamination based upon the following:
   1. Type of surface to be cleaned
   2. Type of contaminant to be cleaned
   3. Tasks or procedures performed in the area
2. After contact with blood or OPIM, surfaces shall be decontaminated with an appropriate disinfectant and protective coverings replaced under the following guidelines:
   1. Work surfaces will be cleaned when visibly contaminated, at the end of the work shift, or at a regularly scheduled frequency (i.e. weekly)
   2. Protective coverings, such as imperviously backed absorbent paper, will be removed and replaced when overtly contaminated or at the end of the work shift
   3. All equipment and reusable containers shall be inspected and decontaminated on a scheduled basis or when visibly contaminated
   4. Contaminated broken glassware shall be collected using mechanical means, such as a brush and dustpan, tongs, or forceps, and be properly decontaminated before disposal. This can be accomplished by either using a chemical disinfectant, or by autoclaving the material.
3. Responsible/Supervisory personnel shall establish and implement written procedures for methods of decontamination appropriate for the equipment to be cleaned, the procedures performed, and the relevant contaminant.

H: Laundry Practices

1. Non-disposable lab coats must be laundered on a regular basis, with transport in sealed plastic bags. Lab coats and other laundry should not be laundered at home but should be laundered using a designated University washing machine or commercial laundry service.
2. Contaminated laundry shall be handled as little as possible and with a minimum of agitation. Contaminated laundry shall be placed in appropriately labeled (biohazard symbol) containers at the location used, without sorting or rinsing. Containers must prevent leakage or soak through from wet laundry during storage or transport
3. University personnel who handle contaminated laundry must wear protective gloves and lab coat or other personal protective equipment as necessary to prevent contact with blood or OPIM.
4. Laundry shall be cleaned in accordance with established written laboratory/department procedures. A standard laundry detergent must be used, and any potentially contaminated laundry must be washed in hot water using a standard washing cycle for clothing If possible, the use of bleach is advised.

I: Training and Education of Employees

1. All University employees who have occupational exposure to blood and OPIM must participate in a training and education program. This training shall be provided at no cost to the employee during normal work hours. General Bloodborne Pathogens training is provided by EH&S. Workplace specific training on bloodborne pathogens hazards and methods to prevent exposure must be provided by the employee’s supervisor or a designated and qualified alternate.
   1. Personnel who are not employees, such as unpaid students and declared volunteers, and who have exposure to bloodborne pathogens in work settings outside of academic classes in which they are enrolled, must receive the same training as employees.
2. The presentation material must be of appropriate content and language so as to be compatible with the educational and literacy level of the employees receiving the training. The person conducting the training shall be knowledgeable in the subject matter to be taught.
3. The training shall be provided when:
   1. Initial assignment is made
   2. At least annually thereafter
   3. When changes, modifications or additions are made to the tasks and/or procedures and need only address the changes in exposure created
4. The training program shall include:
   1. An accessible copy of the standard or directions on how to access or obtain a copy
   2. A general explanation of the epidemiology and symptoms of bloodborne diseases
   3. An explanation of the modes of transmission of the pathogens
   4. An explanation of the exposure control plan and the means of obtaining or accessing a copy
   5. An explanation of the methods of recognizing tasks and activities, which may involve an exposure potential
   6. An explanation of the use and limitations of the control methods employed to reduce exposure potentials
   7. Instruction and information on personal protective equipment, to include types, location, use, and decontamination and disposal methods
   8. An explanation of the basis of select ion of the personal protective equipment
   9. Information on the HBV vaccination, including
      1. Efficacy
      2. Safety
      3. Method of administration
      4. Vaccination benefits
      5. Lack of cost to the employee
   10. Information on the actions to take and persons to contact in an emergency involving blood and/or other potentially infectious materials
   11. An explanation of the procedures to follow in the reporting methods and follow up procedures following a potential exposure
   12. Information on the medical evaluation and follow up procedure that will be offered in the event of an exposure incident
   13. An explanation of the signs and labels and color coding to be use
   14. An opportunity to participate in a question and answer session with the trainer
   15. An opportunity to accept or decline the HBV vaccination (paid for by EH&S
5. Research Laboratories are required to provide, or document, that the employee has received the following additional initial training prior to permitting employees to work with HIV or HBV:
   1. Each employee must demonstrate proficiency in standard microbiological practices and techniques, and in the operations and practices specific to the facility
   2. Each supervisor must have assurance that the employee has previous experience handling human pathogens
   3. A progressive training program for employees with no prior experience must be in place. Such a training program will require demonstrating proficiency prior to advancement to the next level. Actual work with the infectious agents can only occur after successful demonstration of prerequisite microbiological proficiency
6. All training should be documented as outlined in the "recordkeeping" section

J: Recordkeeping

1: Medical and training records are required to be maintained in conjunction with this Plan.

2: Medical Records

The following requirements apply to medical records of employees with occupational exposures:

1. Name and employee number
2. HBV vaccination status documents, including:
   1. Dates of all HBV vaccinations or record of positive HBV antibody titer
   2. Medical records related to the employee's ability to receive HBV vaccinations
3. Copy of results of all required examinations, medical tests and follow up procedures
4. Employee supervisor's copy of the healthcare professional's written notice provided after evaluation of an exposure incident
5. Copy of the information, required by the Standard, provided to the healthcare professional
6. Maintained in confidentiality for the duration of employment plus thirty years
7. All medical records are kept in a confidential file at the BCN Workers’ Compensation Office and may not be released except as required by law without the employee's express written consent. The exception to this are records for vaccinations provided to employees through the Patient Centered Family Medicine Clinic, which will reside in the State of ÁùºÏ±¦µä Immunization database.

3: Training and Compliance Records

The following stipulations and informational requirements apply to the training records:

1. They must contain the dates of the training.
2. They must contain a summary of the training session.
3. They must contain the names and qualifications of the persons conducting the training.
4. They must contain the names of all persons attending the training session.
5. Training records must be maintained for three years from the date of training, and be kept in a specific location. The records may be kept with the PI as well as with EH&S. EH&S will maintain the class roster, training presentation and HBV vaccination declination/acceptance forms. Written correspondence will be kept demonstrating that individuals who accept the vaccination series were provided the opportunity to receive the vaccination.
6. HBV vaccination status documents, including:
   1. Acceptance of HBV vaccination offer
   2. Dates of all HBV vaccinations or record of positive HBV antibody titer
   3. Original signed declination form for personnel who decline vaccination

4: Sharps Injury Log

A sharps injury log must be maintained for all sharps related incidents for at least five years. This log will be maintained by the University Workers’ Compensation Office and will be forwarded to the responsible administrator of the location were the injury took place. This sharps injury log must maintain confidentiality and shall contain:

1. The workplace location of the injury
2. The type and brand of the device involved in the incident
3. An explanation of how the incident occurred

All records shall be made available to the employee, employee representatives, and OSHA and NIOSH upon request for purposes of review and/or copying. Medical records are also to be provided to those persons having express written consent of the employee.

K: Needlestick Action Committee

1. Each workplace that uses sharps devices for patient healthcare must form a committee that will evaluate and make recommendations with regard to sharps awareness issues. This committee must include input from employees who handle the sharps devices directly. This committee’s responsibilities include:
   1. Researching engineering controls that can prevent sharps incidents in the work place
   2. Evaluating these controls over time with regard to the efficacy and usefulness of these controls in the workplace
   3. Reporting these findings to the supervisor of the workplace, and make recommendations as appropriate. These considerations must be documented.

Appendix A:

Exposure Determination by Job Classification

Category 1: Job classifications in which all employees have occupational exposure to bloodborne pathogens

Category 2: Job classifications in which some employees have occupational exposure to bloodborne pathogens

Exposure determination information organized by academic department, job classification and tasks related to job

Department	Category 1 (all)	Category 2 (some)	Tasks creating occupational exposure
Physiology and Cell Biology	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research; Cadaver embalming and dissection
Pathology and Laboratory Medicine	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in diagnosis, teaching, and research
Civil and Environmental Engineering	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Electrical and Biomedical Engineering	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Cell & Molecular Biology	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Biochemistry and Molecular Biology	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Psychology	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Mental health patient care; Use HIV, HBV, HCV, or human material in research
Biology	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research; Cadaver embalming & dissection
Chemistry	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Mechanical Engineering	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Microbiology and Immunology	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Pharmacology	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
School of Public Health	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Agriculture, Nutrition and Veterinary Sciences	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Biochemistry and Molecular Biology	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research
Orvis School of Nursing	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Patient/Client Care
Animal Resources	N/A	Professor Associate Professor Assistant Professor Graduate Research Assistant Postdoctoral Fellow Laboratory Technician Student Employees Registered Volunteers	Use HIV, HBV, HCV, or human material in research

Exposure determination information organized by administrative department, job classification and tasks related to job

Department	Category (all)	Category (some)	Tasks creating occupational exposure
Athletics	Athletic Trainer Student Volunteer Custodians	Equipment Manager	Launder uniforms, towels, rendering first aid; clean up contaminated sharps
Campus Recreation Services	Facility/Fitness Coordinator Programming Coordinator Membership Services Coordinator Director	Instructor Student Worker	Rendering First Aid; cleaning up blood or other OPIM
Child and Family Research Center	Child Care Worker	Coordinator	First Aid provided; cleaning up blood or OPIM
Environmental Health and Safety	N/A	Safety Specialist Industrial Hygienist Lab Safety Manager Hazardous Waste Technicians	Incident response; handling biohazardous waste
Facilities Maintenance	Plumbers Custodians Groundskeepers	N/A	Clean up blood; OPIM; and contaminated sharps
Joe Crowley Student Union	Custodians	N/A	Clean up blood; OPIM; and contaminated sharps
Residential Life	Resident Director Resident Assistant Desk Attendant	N/A	Clean up blood; OPIM; and contaminated sharps
Parking and Transportation Services	N/A	Shuttle Bus Drivers	Designated individuals responsible for blood cleanup
University police	Police Officer Commander	N/A	Apprehending suspects; sharps injury

Appendix B:

Universal Precautions

A: General Guidelines

All material that consists of, or is contaminated with, human blood or other potentially infectious materials (OPIM) must be considered potentially contaminated with bloodborne pathogens. All employees whose activities involve contact with blood or OPIM should consider the following as the minimum precautions.

1. All employees, students and declared volunteers on the BBP Program should routinely use appropriate barrier precautions to prevent skin and mucous-membrane exposure when contact with blood or OPIM is anticipated. Gloves should be worn for touching blood and body fluids or any OPIM, for handling items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. Healthcare workers should change gloves after contact with each patient. All employees should change gloves when contaminated. Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or OPIM to prevent exposure of mucous membranes of the mouth, nose, and eyes. Gowns or aprons should be worn during procedures that are likely to generate splashes of blood or OPIM.
2. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood or OPIM. Hands should be washed immediately after gloves are removed.
3. All employees should take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after procedures. To prevent needlestick injuries, needles should 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 should be placed in puncture-resistant containers for disposal – the puncture-resistant containers should be located as close as practical to the use area. Large-bore reusable needles should be placed in a puncture-resistant container for transport to the reprocessing area.
4. Although saliva has not been implicated in HIV transmission, to minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable.
5. Employees who have exudative lesions or weeping dermatitis should refrain from all direct contact with blood or OPIM and from handling patient-care equipment until the condition resolves.
6. Pregnant healthcare workers are not known to be at greater risk of contracting HIV infection than healthcare workers who are not pregnant; however, if a healthcare worker develops HIV infection during pregnancy the infant is at risk of infection from perinatal transmission. Because of this risk pregnant healthcare workers should be especially familiar with, and strictly adhere to, precautions to minimize the risk of HIV transmission.

Precautions for Laboratories

All blood and other potentially infectious materials should be considered infectious. To supplement the universal precautions listed and detailed in the previous sections, the following precautions are recommended for workers in clinical laboratories.

1. All specimens of blood and OPIM should be put in a well-constructed container with a secure lid to prevent leaking during transport. Care should be taken when collecting each specimen to avoid contaminating the outside of the container and the laboratory form accompanying the specimen.
2. All persons processing blood and OPIM specimens (e.g., removing tops from vacuum tubes) should wear gloves. Masks and protective eyewear should be worn if mucous-membrane contact with blood or OPIM is anticipated. Gloves should be changed and hands washed after completion of specimen processing.
3. For routine procedures, such as histologic and pathologic studies or microbiologic culturing, a biological safety cabinet may not be necessary to prevent exposure to infectious aerosols. However, class II biological safety cabinets should be used whenever procedures are conducted that have a high potential for generating droplets. These include activities such as blending, sonicating, and vigorous mixing.
4. Mechanical pipetting devices should be used for manipulating all liquids in the laboratory. Mouth pipetting must not be done.
5. Use of needles and syringes should be limited to situations in which there is no alternative, and the recommendations for preventing injuries with needles outlined in the universal precautions section should be followed.
6. Laboratory work surfaces should be decontaminated as soon as possible with an appropriate chemical germicide after a spill of blood or OPIM and when work activities are completed.
7. Contaminated materials used in laboratory tests should be decontaminated before reprocessing or placed in bags and disposed of in accordance with the University Biohazardous Waste Plan
8. Scientific equipment that has been contaminated with blood or other potentially infectious materials should be decontaminated and cleaned before being repaired in the laboratory or transported to the manufacturer.
9. All persons should wash their hands after completing laboratory activities and should remove protective clothing before leaving the laboratory.

Appendix C: Washoe County District Health Department

District Board of Health Regulations Governing Solid Waste Management Regulations

Amended, Washoe County District Board of Health: October 27, 2011

The regulations in their entirety may be obtained from the:

Washoe County Health District
1001 East Ninth Street
Post Office Box 11130
Reno, ÁùºÏ±¦µä 89520-0027
(775) 328-2434
(775) 328-6176 (Fax)

The regulations are accessible from the . Go to “Solid Waste Management.” Section 080, Biohazardous Waste, is applicable to management of waste that contains, or is contaminated with, bloodborne pathogens.

Or a copy may be obtained from the EH&S Department:

Applied Research Facility, Room 222
(775) 327-5040
(775) 784-4553 (Fax)