Policies & Procedures



Environment, Health, & Safety


Exposure Control Plan Policy

EH&S Manual Policy
Title:  Exposure Control Plan
SOP Number: 9.009                                                                                                                    
Effective Date:  November 12, 2002                                                                                     
Review Date: November 15, 2013
Replaces: 9.008
Reviewed by:  Cathleen M. Eldridge

The State University of New York College at Plattsburgh is committed to providing a safe and healthful workplace for its staff and faculty. The following Exposure Control Plan has been developed to eliminate where possible or at least minimize the occupational exposure to bloodborne pathogens in accordance with the OSHA Bloodborne Pathogens Standard, Title 29 Code of Federal Regulations 1910.1030


  • Blood - Human blood, human blood components, and products made from human blood.
  • Bloodborne pathogens - Pathogenic microorganisms that are present in the human blood and can infect and cause disease in humans. These pathogens include but are not limited to, Hepatitis B virus (HBV), and Human Immunodeficiency Virus (HIV).
  • Contaminated - The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
  • Exposure Incident - A specific eye, mouth or other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.
  • Occupational Exposure - Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.

Other Potentially Infectious Materials (OPIM)

  1. The following human body fluids
    1. Semen
    2. Vaginal secretions
    3. Cerebrospinal fluid
    4. Synovial fluid
    5. Pleural fluid
    6. Pericardial fluid
    7. Peritoneal fluid
    8. Amniotic fluid
    9. Saliva in dental procedures
    10. Any body fluid visibly contaminated with blood
    11. All body fluids in situations where it is difficult or impossible to differentiate between body fluids;
  2. Any unfixed tissue or organs (other than intact skin) from a human (dead or alive).
  3. HIV-containing cells or tissue cultures, organ cultures, and HIV and HBV-containing culture medium or other solutions.
  4. Blood, organs, or other tissue from experimental animals infected with HIV or HBV.

Regulated Waste

  1. Liquid or semi-liquid blood or other potentially infectious materials;
  2. Contaminated items that would release blood or other potentially infectious materials in the liquid or semi-liquid state if compressed.
  3. Items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling.
  4. Contaminated sharps.
  5. Pathological and microbiological wastes containing blood or other potentially infectious materials.

Standard Precautions

The basic level of infection control precautions meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources.  Hand hygiene is a major component of Standard Precautions, along with cleaning and disinfecting of surfaces.

Transmission-Based Precautions

Airborne, Droplet, or Contact Precautions are recommended to provide additional precaution beyond Standard Precautions to interrupt transmission of pathogens.

Universal Precautions

The treatment of all blood and other potentially infectious materials with appropriate precautions such as:

   - Use gloves, masks and gowns if blood or OPIM exposure is anticipated.
   - Use engineering and work practice controls to limit exposure.
   - Hand hygiene is always the final step after removing and disposing of PPE.


Standard Precautions

As of March 6, 1992 all employees will treat all human body fluids as infectious. Employees will use the appropriate personal protective equipment when the possibility of coming in contact with body fluids is present.

Exposure Control Plan (ECP)

Employees covered by the Bloodborne Pathogens Standard will receive an explanation of the ECP during their initial training, and will have it reviewed in their annual refresher training. All employees will have the opportunity to review this Plan at any time during their work shifts by contacting their supervisor, reviewing the policy on the PSU Campus website, or at the Environmental Health & Safety Department at 564-5009 from 8:00AM till 4:30PM Monday through Friday or by contacting the University Police at 564-2022 at other times.  The plan is available for review, printing or downloading from the Environmental Health and Safety website.  The Department Supervisor will be responsible for reviewing and updating the ECP annually or sooner if necessary to reflect any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

Engineering Controls and Work Practices

Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls that will be used are:

  1. Puncture resistant disposable containers for contaminated sharps and broken glassware.
  2. Ventilated laboratory hoods
  3. Readily accessible hand washing facilities
  4. Emergency eye wash and deluge showers
  5. Safety guidelines for working with needles
  6. Prohibiting eating and drinking in areas where there is a likelihood of occupational exposure.
  7. Requiring that all procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, splattering, and generation of droplets of these substances, while using Universal Precautions.
  8. Placing specimens of blood or other potentially infectious materials in a container, which prevents leakage during collection, handling, processing, storage, transport or shipping.
  9. Examining equipment, which may become contaminated with blood or other potentially infectious materials prior to servicing or shipping and decontaminating such equipment as necessary. New technology for needle and sharps will be evaluated and implemented whenever possible to further prevent accidental needle sticks and cuts. Our engineering controls will be inspected and maintained or replaced by:

    Engineering Controls Inspection, Maintenance, and Replacement

    Area Responsibility Inspection Schedule
    Student Health Center Director Daily
    University Police Officers Chief Daily
    University Police Student Workers Chief Daily
    Nursing Chair Daily
    Custodial Custodial Supervisor Daily
    Physical Education Athletic Director Weekly
    Maintenance Maintenance Supervisor Weekly
    Fieldhouse Fieldhouse Director Weekly
    Student Lifeguards Athletic Director Weekly
    Residence Hall Staff Director Weekly

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Personal protective equipment must be used if occupational exposure remains after instituting engineering and work practice controls or if controls are not feasible. Training will be provided in the use of appropriate personal protective equipment for employee's specific job tasks or procedures they will perform, by the supervisor.

Appropriate personal protective equipment is required for the following tasks:

Appropriate Personal Protective Equipment

Task Equipment
Physical Exam Gloves, clothing protection
First Aid Gloves, clothing protection, mask or Face shield (if appropriate)
Body Fluid clean up Gloves, mask (if chance of aerosol exposure)
Injections Gloves
Laundry Gloves, clothing protection
Plumbing leak repair Gloves, clothing protection
Toilet repair Gloves, clothing protection
Blood Lab Work Gloves, removable shield
Sewage Station Maintenance Gloves, eye, clothing protection

All personal protective equipment will be made readily accessible to all employees through their immediate supervisor. Employees will be issued equipment appropriate to the task and risk of exposure.

Personal Protective Equipment Available

  • Various type Gloves
  • Face shield
  • Disposable Masks
  • Eye Protection (splash proof goggles, Safety glasses)


  1. Wear appropriate gloves when it can be reasonably anticipated that you may have contact with blood or other potentially infectious materials and when handling or touching contaminated items or surfaces. Replace gloves if torn or punctured, contaminated, or if their ability to function as a barrier is compromised.
  2. Following any contact of body areas with blood or any other infectious materials, you must wash your hands and any exposed skin with soap and water as soon as possible. Employees must also flush exposed mucous membranes with water.
  3. Rubber utility gloves may be decontaminated for reuse if their integrity is not compromised. The decontamination procedure will consist of washing the hands, with gloves on, in disinfectant solution.  Discard utility gloves when they show signs of cracking, peeling, tearing, puncturing, or deterioration.
  4. Never wash or decontaminate disposable gloves for reuse or before disposal.
  5. Wear appropriate face and eye protection such as mask with glasses with solid side shields or a chin-length shield when splashes, sprays, splatters, or droplets of blood or other potentially infectious material pose a hazard to the eye, nose, or mouth.
  6. If a garment is penetrated by blood and other potentially infectious materials, the garments must be removed immediately or as soon as feasible.
  7. Repair and/or replacement of Personal Protective Equipment will be at no cost to the employees.
  8. All employees using Personal Protective Equipment (PPE) must:
  • Wash hands immediately or as soon as feasible after removal of gloves or other PPE.
  • Remove PPE before leaving the work area and after the garment becomes contaminated.
  • Place used PPE in appropriately designated areas or containers when being stored, washed, decontaminated, or discarded. 

Container Areas

  • Biohazard waste containers are set up in the training room at the Fieldhouse, in the Student Health Center and in the basement of Hudson Main
    The current contract for removal of regulated medical waste is with BioServ

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All employees who have or are reasonably anticipated to have occupational exposure to bloodborne pathogens will receive training consisting of information on the epidemiology of bloodborne pathogen diseases.  The training program will cover the following elements:

  1. A copy and explanation of the standard
  2. Epidemiology and symptoms of bloodborne pathogens
  3. This Exposure Control Plan and how to obtain a copy
  4. Methods to recognize exposure tasks and other activities that may involve exposure to blood.
  5. Use and limitations of Engineering Controls, Work Practices, and Personal Protective Equipment.
  6. Personal Protective Equipment - types, use, where obtained, removal, handling, decontamination, and disposal
  7. PPE-basis for selection
  8. Hepatitis B Vaccine - offered free of charge. 
  9. Emergency procedures - for blood and other potentially infectious materials
  10. Exposure incident procedures.
  11. Post - exposure evaluation and follow up
  12. Signs and labels, color coding
  13. Questions and answers

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Hepatitis B Vaccination

The Environmental Health & Safety Department will provide supervisors information on Hepatitis B Vaccinations addressing its safety, benefits, efficacy, methods of administration and availability.

The Hepatitis B Vaccination series will be made available at no cost to the employees who have exposure to blood or other potentially infectious materials.  If an employee chooses not to receive the vaccination he or she must sign a statement to the effect. Employees who decline may request and obtain the vaccination at a later date at no cost. A copy of documentation of refusal of the HB vaccination should be forwarded to the Environmental Health & Safety Department.

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Post Exposure Evaluation, Follow-up and Procedures for Reporting, Documenting and Evaluating the Exposure

Should an exposure incident occur, contact the Environmental Health & Safety Department or University Police. Each exposure must be documented by the employee on an "Exposure Report Form".  The employee should inform their supervisor and go to the Emergency Room if necessary.  During business hours, treatment may be available from the Center for Occupational Health and Wellness at CVPH.

The following elements will be performed:

  1. Document the routes of exposure and how exposure occurred.
  2. Identify and document the source individual, unless the employer can establish that identification is not feasible or prohibited by State or local law.
  3. Obtain consent and test source individuals blood as soon as possible to determine HIV and HBV infectivity and document the source's blood test results.
  4. If the source individual is known to be infected with either HIV or HBV, testing does not need to be repeated to determine the known infectivity.
  5. Provide the exposed employee with the source individual test results and information about applicable disclosure laws and regulations concerning the source identity and infectious status.
  6. After obtaining consent, collect exposed employee's blood as soon as feasible after exposure incident and test blood for HBV and HIV serological status.
  7. If the employee does not give consent for HIV serological testing during the collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days.

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Health care professionals responsible for employee's HB vaccination and post-exposure evaluation and follow-up should give the employee a copy of the OSHA BloodBorne Pathogen Standard. The employee's supervisor will ensure that the health care professional evaluating an employee after an exposure incident receives the following:

  1. A description of the employee's job duties relevant to the exposure incident.
  2. Route of exposure
  3. Circumstances of exposure
  4. Relevant employee records including vaccination status

Healthcare Professionals Written Opinion

The examining physician will provide the employee with a copy of his written opinion within 15 days after completion of the evaluation.

For HB vaccinations, the healthcare professionals written opinion will be limited to whether the employee requires or has received the HB vaccination.

The written opinion for post-exposure evaluation and follow-up will be limited to whether or not the employee has been informed of the results of the medical evaluation and any medical conditions which may require further evaluation and treatment.

All other diagnoses must remain confidential and are not to be included in the written report.

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  1. Decontaminate work surfaces with an appropriate disinfectant after completion of procedure, immediately when overtly contaminated, after any spill of blood or other potentially infectious materials, and at the end of the work shift when surfaces have become contaminated since the last cleaning.
  2. Remove and replace protective coverings such as plastic wrap and aluminum foil when contaminated.
  3. Inspect and decontaminate on a regular basis, reusable receptacles such as bins, pails, and cans that have likelihood of becoming contaminated. When contamination is visible, clean and decontaminate receptacles immediately, or as soon as feasible.
  4. Always use mechanical means such as tongs, forceps, or a brush and a dust pan to pick up contaminated broken glassware; never pick up with hands even if gloves are worn.
  5. Store or process reusable sharps in a way that ensures safe handling.
  6. Place regulated medical waste in closeable and labeled color-coded containers. When storing, handling, transporting or shipping, place all regulated waste in leak-proof containers.
  7. All sharps should be discarded in appropriate rigid, leak-proof containers.
  8. Sharps containers will be disposed of with the regulated medical waste. 
  9. Never manually open, empty, or clean contaminated sharps disposal containers.
  10. All regulated waste will be disposed of through the medical waste contractor (BioServ) and coordinated by the Environmental Health & Safety Department.


The Fieldhouse Staff is responsible for the laundry and care of the athletic uniforms and equipment. The following requirements must be met, with respect to contaminated laundry:

  1. Handle contaminated laundry as little as possible and with a minimum of agitation.
  2. Use appropriate personal protective equipment when handling contaminated laundry.
  3. Place wet contaminated laundry in leak-proof, labeled or color coded containers before transporting.
  4. Bag contaminated laundry at its location of use.
  5. Never rinse contaminated laundry in areas of its use.
  6. Use red bags or those marked with the biohazard symbol unless universal precautions are in use at the facility and all employees recognize the bags as contaminated and have been trained in handling the bags.
  7. When handling or sorting contaminated laundry, utility gloves and other personal protective equipment shall be worn.


All regulated medical waste shall be disposed of in red leak-proof bags identified with a biohazard symbol on it.  Waste is currently being collected by BioServ.  Soiled materials that will not release blood or other potentially infectious materials in the liquid or semi-liquid state if compressed, or are caked with dried blood or other potentially infectious materials and are not capable of releasing these materials during handling are NOT regulated medical waste.

Major Incidents

In the event a situation occurs where a large volume of blood is spilled, an outside vendor will be contacted to perform the cleanup.

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Medical Records

Medical Records are maintained for each employee with occupational exposure in accordance with 29 CFR Part 1910.20.  The Human Resource Services Office is responsible for maintenance of the required medical records and they are kept at that office.  In addition to the requirements of 29 CFR Part 1910.20, the medical record will include:

  1. The name and social security number of the employee;
  2. A copy of the employee's Hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccinations;
  3. A copy of all the results of examinations, medical testing, and follow-up procedures as required by the standard;
  4. A copy of all healthcare professionals written opinions as required by the standard

All employee medical records will be kept confidential and will not be disclosed or reported without the employee's express written consent to any person within or outside the workplace except as required by the standard or as may be required by law.

Employee medical records shall be maintained for at least the duration of employment plus 30 years in accordance with 29 CFR Part 1910.20,

Employee medical records shall be provided upon request to the employee or anyone having written consent of the employee within 15 working days.

Training Records

The Environmental Health & Safety Department will maintain Bloodborne Pathogen training records at the office. The training records will consist of:

  1. The dates of the training sessions;
  2. The contents or a summary of the training sessions;
  3. The names and qualifications of persons conducting the training;
  4. The names and job titles of all persons attending the training sessions

Training records will be maintained for a minimum of three years from the date on which the training occurred. Employee training records will be provided upon request to the employee or the employee's authorized representative within 15 working days.

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Appendix A

Job Classifications in Which All Employees Have Occupational Exposure to BloodBorne Pathogens

Job Title Department
Medical Doctor Student Health Service
Physicians Assistant Student Health Service
Medical Technician Student Health Service
Registered Nurse Student Health Service
Licensed Practical Nurse Student Health Service
University Police Officer University Police
Athletic Trainer Physical Education
Equipment Manager Physical Education
Athletic coach Physical Education
Lifeguard Physical Education
Student Supervisor Physical Education
Security Fieldhouse
Janitor/Cleaner Janitorial
Plumber Maintenance & Operations
Nursing Faculty Nursing faculty on hospital assignment
Environmental Health & Safety Staff Environmental Health & Safety Department

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Appendix B

Job Classifications and Work Practices in Which Some Employees Have Occupational Exposure to BloodBorne Pathogens

Job Title Department/Location Task Procedure
Custodian Academic Area Body Fluid Cleanup
Custodian Residence Hall Area Body Fluid Cleanup
Residence Assistants Campus Life Floor Supervision
Residence Director Campus Life Dorm Supervision
Maintenance Mechanic M&O Plumbing Repair
Plumber M&O Plumbing Repair
Plant Utility Engineers CHP Sewage Station Work

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Appendix C

Expsure Incident Packet:


All above forms must be completed when an exposure incident occurs.

Contact Information

Cathleen Eldridge, Director
Phone: 564-5009
Fax: 564-5082
Email: eldridcm@plattsburgh.edu

Location and Hours:
136A Service Building
Monday - Friday 8:00 am to 4:30 pm