Bloodborne Pathogens Exposure Control Plan

242 FW 12
Amended By
Decision Memorandum, “Approval of Revisions to ~350 Directives to Remove Gender-Specific Pronouns,” 6/22/2022
Originating Office
Safety Operations


This Bloodborne Pathogens Exposure Control Plan has been developed per requirements in 29 CFR 1910.1030, Bloodborne Pathogens and Service policy (242 FW 12, Bloodborne Pathogens).

Facility Name: ______________________________________________________________________

Region: ___________________________________________________________________________

Address: __________________________________________________________________________

_____________ ____________________________________________________________________


Bloodborne Pathogen Point of Contact for this facility is ____________________________

[insert the name of the Project Leader or Bloodborne Pathogens Program Coordinator who will complete this plan and is responsible for giving employees additional information if they request it]

Date plan was written: _____________________________

1. Purpose. This plan lists our actions to eliminate or minimize your occupational exposure to blood or other potentially infectious materials (OPIM).

2. Bloodborne Pathogens Program Responsibilities. [insert the name of the Project Leader or designated individual] is the Bloodborne Pathogens Program Coordinator. [His/Her/Their] responsibilities include inspections, review of records, and periodic program audits.

3. Plan Contents. This plan includes the following:

  • Terms you need to know.
  • Name of the Bloodborne Pathogens Program Coordinator.
  • Exposure Determination.
  • Work practices you must follow to protect yourself from exposure to bloodborne pathogens or OPIM.
  • Personal protective equipment you must use.
  • Hepatitis B Vaccine Program.
  • Procedures for inoculating “Good Samaritan” first aid responders.
  • Post-exposure medical examination and followup.

·  A list of jobs we believe have the potential for exposing you to bloodborne pathogens or OPIM.

·  Training you must receive.

·  Hepatitis B Immunization Consent/Refusal Form.

·  Instructions for physicians who evaluate employees.

4. Definitions.

A. A Biohazard is any viable infectious agent that presents a risk or a potential risk to you.

B. Blood means human blood and human blood components.

C. Bloodborne Pathogens are microorganisms in human blood or OPIM that are capable of causing disease in people who are exposed to them. OSHA specifically identifies Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) as bloodborne pathogens.

D. An Exposure Incident is when you have contact with human blood or OPIM while doing your job. This includes contact through non-intact skin, eye, mucous membrane, or parenteral contact.

E. A Good Samaritan is someone who voluntarily provides emergency assistance to another person who is injured or sick, such as someone in your workplace. The term comes from statutes that States enact to protect healthcare providers and other rescuers from being sued when they provide emergency aid to another person.

F. Occupational Exposure means that, because of the job you do, you may at some point be exposed to bloodborne pathogens or OPIM.

G. Other Potentially Infectious Materials (OPIM) are human body fluids (other than blood) or human tissue that may contain blood or transmit pathogens.

H. Parenteral means the breaking of skin or other situations that result in you being exposed to another person’s blood or body fluids.

I. Regulated Waste:

(1) Includes:

     (a) Liquid or semiliquid blood- or OPIM-contaminated items that would release blood or OPIM if compressed,

     (b) Items that are caked with dried blood or OPIM because they are capable of releasing these materials during handling,

     (c) Contaminated sharps, and

     (d) Pathological and microbiological waste containing blood or OPIM.

(2) Examples of regulated waste include:

     (a) First aid bandages,

     (b) Medical needles,

     (c) Material used in cleaning up blood or human body fluids, and

     (d) Gloves, clothing, or other materials contaminated with blood or OPIM.

J. Sharps are needles or other sharp instruments such as scalpels that may be used or found within your work setting.

K. Universal Precautions are procedures used to control infection by treating all human blood and human body fluids as if they were infectious.

5. Making Exposure Determinations.

A. Evaluation of your workplace has indicated that you may have a potential for exposure to blood or OPIM while performing your job at this facility/workplace. Job classifications and specific employees who may have the potential for exposure are listed in FWS Form 3-2282, which is attached to this plan. This determination was made by evaluating every task performed and the hazards associated with those tasks. The potential for exposure risks was determined prior to factoring in any personal protective equipment we provide you to wear while doing your job.

B. If we have trained you to give first aid, CPR, or operate an AED and first aid, CPR, or AED response is a part of your job, we consider you occupationally exposed. [Use this paragraph only if it applies to your facility/workplace.]

C. If we have trained you to give first aid, CPR, or operate an AED and first aid, CPR, or AED response is not a part of your job, we do not automatically consider you occupationally exposed. If you render first aid in response to injuries resulting from workplace accidents, you are giving emergency first aid on a voluntary basis as a “Good Samaritan.”

D. If you are exposed while acting as a Good Samaritan, you are covered by this plan and must follow the post-exposure procedures in section 8.

6. Avoiding Exposure to Bloodborne Pathogens and OPIM. Because you do not perform invasive medical treatment or provide intravenous medication at [Facility/Workplace Name], any exposure to bloodborne pathogens and OPIM would come from routine or emergency first aid treatment of common workplace injuries and illnesses. You must use universal precautions to prevent contact with blood or OPIM and use general safety rules to prevent the spread of viral and bacterial organisms. You must:

A. Consider all blood or OPIM infectious, including animal blood or body fluids, regardless of the source.

B. Treat all human body fluids and items soiled with human body fluids as if they were contaminated with Hepatitis A or B Virus (HAV/HBV) or HIV.

C. Wash exposed areas (hands, arms, etc.) with antibacterial soap before and immediately after giving first aid. Hand washing facilities with sinks, soap dispensers, and paper towels are located in every bathroom in this facility. Antiseptic towelettes must be readily available for use if there are no handwashing facilities available in your normal workplace or if you are working at a location remote from your normal workplace.

D. Even if you were wearing personal protective gloves, wash your hands and other potentially contaminated skin areas with soap and water.

E. Clean and decontaminate spills of blood after an incident using the following procedures:

  • Wear gloves and eye protection.
  • If you anticipate there will be splashing, wear an impervious apron.
  • Remove visible material with disposable towels.
  • Disinfect the area with an approved germicide or bleach solution (i.e., typically a 1:10 solution of water and bleach). [Tell employees where the solution is located in the facility/workplace.]
  • Place soiled materials in a bag. Seal the bag. Place that bag inside a red biohazard bag and seal it. If you do not have a biohazard bag, place the first bag in a second bag and write “Biohazard” in large letters on the second bag. [You should have red bags marked with the word “Biohazard” at your facility or workplace. Tell the employees where the bags are located.]
  • Dispose of the bag in accordance with 561 FW 13. [Insert facility/workplace medical waste disposal procedure.]
  • Wash hands with antiseptic cleanser.

F. Do not eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in work areas where there is a potential you will be exposed to a health hazard.

G. Do not store food or drinks in refrigerators, freezers, or cabinets where blood or OPIM is stored or in other areas of possible contamination. Those refrigerators, freezers, or cabinets where blood or OPIM are stored must be labeled with a “Bio-hazard warning” label.

7. Personal Protective Equipment. We pay for and provide personal protective equipment to prevent blood or OPIM from reaching your clothing, skin, eyes, mouth, or other mucous membranes. Bloodborne pathogen/OPIM personal protective equipment kits should be provided in occupational settings where the possibility of exposure may arise and should be located with medical aid devices (e.g., AED) and first aid kits. We also must train you how to wear the equipment.

A. Available Personal Protective Equipment:

(1) We have the following protective equipment available for you to use:  [Describe who has the equipment (i.e., facility manager, safety representative) or where it is located (i.e., in the personal protective equipment locker).]

  • Packaged bloodborne pathogen protective kits containing [at a minimum] disposable non-latex gloves, surgical mask, antimicrobial/disinfectant wipe, absorbent treatment material (gauze pads, tape, etc.) and waste bags. (Note: Some people are sensitive or allergic to latex, so we approve and use only non-latex gloves).

(2) One-way resuscitation devices and disposable non-latex gloves are available in first aid kits located [tell where they are located within the facility/workplace].

B. Using Personal Protective Equipment: You should use the following information as a general guide:

Personal Protective Equipment Guide






Control of bleeding (i.e., spurting blood)





Control of bleeding (i.e., minimal blood)



Defibrillator use – blood from shaving patient chest



Taking blood pressure


[Add any facility/workplace-specific emergency that might arise]


C. Contaminated Personal Protective Equipment:

(1) Remove all garments that were or may have been in contact with blood or OPIM as soon as possible.

(2) Remove all personal protective equipment before you leave the facility/workplace.

(3) Place all used personal protective equipment in a biohazard bag and dispose of it as required in paragraph 6E of this plan.

(4) Do not wash or attempt to decontaminate disposable gloves. We must discard and replace them if they are contaminated, torn, punctured, or no longer a barrier to blood and OPIM. Notify [name of responsible person] when you have to discard gloves or any other personal protective equipment so that it can be replaced.

8. Post-Exposure Procedures.

A. You must IMMEDIATELY report to your supervisor any suspected exposure to blood or contact with human body fluid (via broken skin, human bites, needle sticks, etc.).

B. You must also report the suspected exposure to [facility/workplace person responsible for the bloodborne pathogens program] immediately. [He/She/They] will give you information about what we can do for you and decide if you should be included in the Hepatitis B Immunization Program.

9. Hepatitis B Virus (HBV) Vaccination Program.

A. Vaccine Eligibility:

(1) If you are on the Occupational Exposure list (FWS Form 3-2282), you are eligible to receive a free HBV vaccination. We must offer you the HBV vaccine within 10 working days of your initial assignment to a position listed in FWS Form 3-2282. Note: HBV vaccination is not mandatory. You may decline the vaccine. If you decide later that you want the vaccine, tell your supervisor or [the person responsible for the facility/workplace program], and we will give you the vaccine at our expense.

(2) Regardless of whether you accept or decline the vaccine, you must complete the HBV Immunization Consent/Declination Form (FWS Form 3-2283). We keep the form in your employee medical folder.

B. Good Samaritans and the HBV Vaccination.

(1) We must offer you the HBV vaccine at our expense within 24 hours from the time that you were potentially exposed. You receive the vaccination as a precaution, whether you were actually exposed to blood/OPIM or not.

(2) Any time you give first aid or CPR at your workplace, you must tell your supervisor. Your supervisor must make sure that proper precautions concerning the incident are followed and that, if you haven’t already been vaccinated, we offer the HBV vaccine to you within 24 hours.

10. The Service’s Responsibilities after Exposure. If you come into contact with blood or OPIM from an injured or ill person and from an open wound or mucous membrane, or if you are injured by a sharp object that was contaminated with someone else’s blood or OPIM, the following things must happen:

A. After you report the incident to your supervisor (see section 8), your supervisor should collect the blood you were exposed to so that it can be medically tested.

B. The occupational exposure incident must be entered into the Department of the Interior Safety Management Information System ( The incident report should include the names of everyone involved, what happened, when and where it happened, and any other information that is important.

C. [Person responsible for the Bloodborne Pathogens Program at the facility/workplace] must contact the person whose blood you were exposed to and request that he/she/they be tested for HIV/HAV/HBV at our expense. We must arrange for a test for that person as soon as possible after he/she/they consents. Note: The person who exposed you is not required by law to submit to blood testing. His/her/their future employment with this facility/workplace will not be adversely affected for refusing to be tested.

D. At no cost to you, we must offer services from a licensed physician or health care worker and tests from an accredited laboratory. We will request that you consent to baseline blood work and subsequent testing for HIV/HAV/HBV. We will provide the evaluating physician with information regarding the nature of the testing, followup care, and documentation needed per policy requirements. You can find a copy of the instructions in 242 FW 12, Exhibit 2, which is attached to this plan. Following are the services we must offer to you:

(1) Blood testing for HIV/HAV/HBV. If you consent to testing, your blood will be tested for HIV/HAV/HBV. If you test free of those viruses after the initial blood test, we must arrange for you to be retested 6 weeks, 12 weeks, and 6 months after exposure. During that period of time, you should follow the recommendations given to you by the evaluating physician.

(2) Medical evaluations including immune globulin for HBV should follow the U.S. Public Health Service guidelines.

(3) Counseling and illness evaluation.

E. The health care professional who evaluates you must provide us with a written report that indicates that you have been informed of the evaluation results and that you were counseled about any exposure-related conditions. All other findings are confidential.

(1) We must give you a copy of the written report within 15 days of the evaluation.

(2) We keep the written report in your confidential employee medical file (see sections 11 and 13).

11. Confidentiality of Medical Evaluations and Blood Test Results. We must keep all information concerning both the exposed employee and the person causing the exposure in accordance with the safeguards identified in Privacy Act system OPM/GOVT – 10. We only grant access to such records to those people authorized in accordance with the routine uses identified by OPM/GOVT – 10. You may obtain a hardcopy of OPM/GOVT – 10 from your Project Leader, supervisor, or the Service’s Privacy Act Officer.

12. Training

A. Training for Employees on the Occupational Exposure List (FWS Form 3-2282). [Person responsible for Bloodborne Pathogens Program training at the facility/workplace] must make sure you are trained when you are initially assigned to an occupationally exposed position, and then annually for as long as you are in that position. The training must include the following:

•  Basic requirements of the OSHA Bloodborne Pathogens standard.

•  Where you can read or get a copy of the OSHA Bloodborne Pathogens standard.

•  Information on bloodborne diseases and how they are transmitted.

•  The contents of our Exposure Control Plan.

•  Tasks that may expose you to blood or OPIM at this facility/workplace.

•  Control methods we will use to minimize your exposure to blood or OPIM.

•  Information on types, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment.

•  Signs, labels, and posters used here.

•  HBV vaccine program.

•  Post-exposure evaluation and followup procedures.

Note: If the Service trains you in CPR/first aid/AED, we will offer you the same or similar bloodborne pathogens training annually.

B. Training for Employees NOT on the Occupational Exposure List. We will provide general awareness training through booklets, posters, the Department’s online course, or other forms of information to employees who are not on the occupational exposure list. We will also provide a basic overview of the program requirements. If you have questions about the bloodborne pathogens program, you can also contact [Person responsible for bloodborne pathogens program training at the facility/workplace].

13. Records. The Bloodborne Pathogens Standard requires us to keep medical treatment, exposure, immunization (including the consent/refusal form), and training records on all employees who are on our Occupational Exposure List or who have an exposure incident. Your supervisor must make sure that all records required by the OSHA standard are completed.

A. Training Records. We keep the following information in your training records for 3 years from the date of training:

•  Your name.

•  Training dates.

•  Contents or summary of the training sessions.

•  Names and qualifications of the people who train you.

B. Content of the Employee Medical File. We keep and maintain the following information in your employee medical file in accordance with 5 U.S.C. 552a (The Privacy Act of 1974) for length of employment. We send post-employment records to the National Personnel Records Center. They maintain them for 30 years.

•  Your name.

•  Your social security number.

•  Hepatitis B vaccination status.

•  Hepatitis B vaccination consent/refusal form.

•  Post-exposure evaluation (if appropriate).

•  Followup procedures results (if appropriate).

•  Healthcare professional’s written opinion (if appropriate).

C. Access to the Employee Medical File. Contingent on a documented need to know, we may only provide information contained in your records to the following:

•  You.

•  Anyone to whom you give written consent.

•  Official representatives of OSHA.

•  Official representatives of the National Institute for Occupational Safety and Health (NIOSH).

•  Servicing Human Resources office representative.