Intranet graphic Business Policy Letters


TO: All Members of the University Community 97:47
DATE: April 1997

Bloodborne Pathogen Policy
(Supersedes 94:4)

  1. PURPOSE

    The purpose of this policy is to provide health protection measures for employees who may be occupationally exposed to human blood or other potentially infectious material. Specific rules and procedures are hereby established so employees are provided with the necessary protection when occupationally exposed. This policy is established in compliance with Michigan Department of Consumer and Industry Services rules, Bloodborne Infectious diseases, R 325.70001 - R 325.70018. (http://www.state.mi.us/execoff/admincode/data/ac00325/s70001.txt)

  2. SCOPE

    1. This policy shall apply to University colleges and departments who have employees with occupational exposure to blood or other potentially infectious materials. Occupational exposure means reasonably anticipated skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materials that may result form the performance of an employee's duties without the use of personal protective equipment. Colleges and departments that have been identified as having at least some employees with occupational exposure are listed in Appendix A.
    2. Section VII of this policy shall apply to all University colleges and departments.
  3. POLICY ADMINISTRATION

    The Environmental Health and Safety Office shall be responsible for the overall administration of this policy. All University departments and employees shall cooperate fully with the Environmental Health and Safety Office and comply with the requirements set forth in Michigan Department of Consumer and Industry Services (CIS) rules, Bloodborne Infectious Diseases, R 325.70001 - R 325.70018.

  4. EXPOSURE CONTROL PLANS

    1. Each college or department with employees within the scope of this policy, shall establish a written Exposure Control Plan as required by OSHA regulation CIS rule R 325.70004, Exposure control plan. The Exposure Control Plan shall contain at least the following elements:
      1. A list of job classifications in which at least some of the employees in those job classifications have occupational exposure.
      2. The practices and procedures, which will be used to comply with CIS, rule R 325.70005 - R 325.70011.
      3. The method of complying with CIS rule R 325.70014, Communication of hazards to employees.
    2. All Exposure Control Plans shall be submitted to the Environmental Health and Safety Office and shall be subject to the approval of the Task Force on Communicable Diseases.
    3. All Exposure Control Plans shall be reviewed and updated annually by the college or department and submitted to the Environmental Health and Safety Office for approval.
    4. Department employees shall comply with the provisions of their department's Exposure Control Plan.
  5. HEPATITIS B VACCINATION

    1. The hepatitis B vaccination series shall be made available to employees within the scope of this policy. The vaccination shall be made available at no cost to the employee.
    2. All vaccinations shall be administered by or under the direction of the Birkam Health Center physician.
    3. An employee who declines hepatitis B vaccination, after having been fully informed of the risks and benefits of the vaccination shall sign the required declination statement (Attachment B). The department director/head shall submit the signed statement to the Birkam Health Center to be included in the employee's medical records.
    4. The Birkam Health Center shall submit to the Environmental Health and Safety Office the names of employees who have been immunized, are considered to be immune by antibody testing, or have declined immunizations.
  6. POST-EXPOSURE EVALUATION AND FOLLOW-UP

    1. All exposure incidents shall be reported immediately to the Birkam Health Center which shall make a confidential medical evaluation and follow-up in accordance with CIS rule R 325.70013, Vaccination and postexposure follow-up.
    2. An exposure incident means a specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials that result from the performance of an employee's duties.
  7. DESIGNATED FIRST AID PROVIDER

    1. Some employees may be assigned by their department director/head, with the consent of the employee, to provide emergency first aid only as a collateral duty responding solely to injuries to faculty, staff or students, and generally at the location where the injury occurred. For the purposes of this policy, these employees shall be referred to as "designated first aid providers". This does not include employees who provide first aid on a regular basis or are otherwise within the scope of this policy.
    2. Whenever first aid treatment is provided by a designated first aid provider and blood or other potentially infectious material is present, the first aid provider shall report immediately to the Birkam Health Center for evaluation and treatment. If the Birkam Health Center is closed the first aid provider shall proceed to the Mecosta County Medical Center and notify the Health Center as soon as possible.
    3. Designated first aid providers shall be considered as having occupational exposure but will not be offered the hepatitis B vaccination unless and until they render first aid assistance where blood or other potentially infectious materials are present. The full hepatitis B vaccination series shall be made available as soon as possible, but in no event later than 24 hours, to all unvaccinated designated first aid providers who rendered first aid assistance to faculty, staff or students, where the presence of blood or other potentially infectious materials were involved regardless of whether or not a specific "exposure incident" has occurred.
    4. Designated first aid providers shall participate in an annual training program provided by the Environmental Health and Safety Office on exposure control procedures and the requirements of this policy and State rules. The employee's department shall arrange for any necessary first aid or CPR training.
  8. INFORMATION AND TRAINING

    1. Each University college or department with employees within the scope of this policy, see Attachment A, shall ensure that all of its employees with occupational exposure participate in an annual training program as specified in CIS rule R 325.70016.
    2. As part of the training program, a copy of this policy, CIS rules, and the college or departments Exposure Control Plan shall be provided to each participant.
    3. Training records as specified in CIS rule R 325.70015 shall be completed for each training session and submitted to the Environmental Health and Safety Office.
  9. MEDICAL RECORDS

    The Birkam Health Center shall maintain all medical records as specified in CIS rule R 325.70015.

Richard Duffett
Vice President for Administration and Finance

Contact: Environmental Safety Office

Appendix A

Colleges and departments that have been identified as having employees with occupational exposure include:

1. College of Allied Health Sciences
2. College of Optometry
3. College of Pharmacy
4. Animal Care
5. Athletics
6. Birkham Health Center
7. Physical Plant
8. Public Safety
9. Tot's Place
10. University Recreation
11. Criminal Justice

Appendix B

Sample waiver statement when an employee declines the Hepatitis B vaccination

I understand that, due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the hepatitis B vaccine, at no charge. However, I decline the hepatitis B vaccine at this time. I understand by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the hepatitis B vaccine, I can receive the vaccination series at no charge.

Employee name:
Employee signature:
Date: