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Bloodborne Pathogen Exposure Control Plan

Last Updated: 07/15/2019

The purpose of the Injury Illness Prevention Program (IIPP) is to outline Cal Maritime's environmental health and safety requirements, expectations, and responsibilities in order to achieve effective campus safety performance through Integrated Safety Management (ISM). The Bloodborne Pathogen Exposure Control Plan is a subject specific component the supports the overall University IIPP.

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It is the policy of California State University Maritime Academy (Cal Maritime) to maintain, insofar as is reasonably possible, an environment that will not adversely affect the health, safety and well-being of students, employees, visitors, and the surrounding community. Because not all working environments can be made completely safe from potentially hazardous bloodborne pathogens, the University has established a Bloodborne Pathogen Exposure Control  Program (Program) that will establish protections and safeguards for University employees exposed to these hazards.

It is the policy of the Cal Maritime to maintain a safe and healthy work environment for each employee (including student and contract employees), and to comply with all applicable occupational health and safety regulations. This Injury and Illness Prevention Program (IIPP) is intended to establish a framework for identifying and correcting workplace hazards within the department, while addressing legal requirements for a formal, written IIPP.

To assist Cal Maritime in providing a safe, compliant, environmentally sound, and more sustainable operation, each department or operational unit is expected to review, understand, and follow the guidance provided in the Injury Illness Prevention Program components and the and the function of the integrated campus safety management system (ICSMS) as related to operations under their control.

In a proactive behavior based environmental health and safety model that entire campus community participation reflects a process that embraces the ability to;

  •  Eliminate adverse conditions which may result in injury or illness,
  •  Recommend the establishment of programs to raise safety consciousness in the community, and
  • Achieve and maintain a beneficial relationship through continuing communication on issues relating to environmental health and occupational safety

Employees (Including Student workers)

It is the responsibility of all faculty and staff to proactively participate and subsequently comply with all applicable health and safety regulations, Cal Maritime policies, and established safe work practices. This includes, but is not limited to:

  • Observing health and safety-related signs, posters, warning signals and directions.
  • Learning about the potential hazards of assigned tasks and work areas.
  • Taking part in appropriate health and safety training.
  • Following all safe operating procedures and precautions.
  • Participating in workplace safety inspections
  • Using proper personal protective equipment.
  • Inform coworkers and supervisors of defective equipment and other workplace hazards without fear of reprisal.
  • Reviewing the building emergency plan and assembly area.
  • Reporting unsafe conditions immediately to a supervisor, and stopping work if an imminent hazard is presented.

Department of Safety and Risk Management (SRM)

The Director of Safety and Risk Management (SRM), as delegated by the University President, is responsible for the implementation and administrative management for Cal Maritime's Injury Illness Prevention Program (IIPP) that meets the requirements of California Code of Regulations (CCR), Title 8, section 3203) as well as other applicable California and Federal Occupational Safety and Health (Cal-OSHA) requirements. This Program represents a best management safe work practice or regulatory specific component of the IIPP. 

  • Provide advice and guidance to all university personnel concerning IIPP compliance requirements;
  • Provide centralized monitoring of campus activities related to implementation of campus IIPP;
  • Ensure scheduled periodic safety inspections are performed in compliance with regulatory requirements and assist management staff in identifying unsafe or unhealthful conditions;
  • Ensure safety and health training programs comply with regulatory requirements and university policy;
  • Oversee the maintenance of safety and health records consistent with the requirements of this document and regulatory mandates;
  • Ensure program audits, both scheduled and as required by a process, equipment or personnel change, or by a safety program mandate, are performed;
  • Interpret existing or pending safety and health legislation and recommend appropriate compliance strategies to university personnel;
  • Maintain centralized environmental and employee monitoring records, allowing employee access as directed by law.

Deans, Directors, Department or Operating Unit Management (DM)

Campus Department or Operating Unit Head Management (DM) have an integral campus role and shall have a thorough understanding of Injury Illness Prevention Program components and the function of the integrated campus safety management system (ICSMS) as related to operations under their control.

  • The DM have primary authority and responsibility to ensure the health and safety of the department's faculty, staff and students through the implementation of the Injury Illness Prevention Program components. This is accomplished through a collaborative approach with SRM by communicating Cal Maritime's campus emphasis on health and safety, analyzing work procedures for hazard identification and correction, ensuring regular workplace inspections, providing health and safety training, and encouraging prompt employee reporting of health and safety concerns without fear of reprisal.
  • The "Owner Department" is responsible to identify hazardous activities in their workplace and design into locations engineering controls such as guards, barriers, edge protection, etc., to prevent access to a known hazard.  Only when engineering controls cannot be used or implemented, personal protective equipment (PPE) may be used to aid in controlling hazards to personnel in a Department's operation.
  • The department owning or exposing personnel to hazards is responsible for the selection of the proper equipment based upon a hazard analysis of work tasks. In addition, Owner Departments must ensure regulatory applicable training is provided to their personnel who use the equipment, keep the records of training completed, and schedule periodic inspections of all equipment under their ownership or control.
  • Toward this end, the Department owning the equipment must:
  •       Notify SRM of training needs to designated personnel. Refer to section 4 of this document for training requirements applicable to this Program.
  •       Notify SRM when new equipment is purchased so that it can be inspected and added to the JHA and Equipment inventory.
  •       Schedule with SRM a periodic inspection.
  •       Render unusable and then dispose of any equipment that is in any way questionably unsafe as determined by the inspector or the person using the equipment.
  • DM's are encouraged to designate an individual as the department safety coordinator, to assist with the specific operational environmental, health and safety process management components. 

Supervisors and Principal Investigators

Supervisors play a key role in the implementation of the Cal Maritime's Injury Illness Prevention Program components. Supervisors may be Management, Senior Research Associates, Department Chairs, Principal Investigators, or others who oversee a project and/or staff. They are responsible for but not limited to:

  • Communicating to their staff and students about Cal Maritime campus's emphasis on health and safety.
  • Ensuring periodic, documented inspection of workspaces under their authority.
  • Promptly correcting identified hazards.
  • Modeling and enforcing safe and healthful work practices.
  • Providing appropriate safety training and personal protective equipment.
  • Implementing measures to eliminate or control workplace hazards.
  • Stopping any employee's work that poses an imminent hazard to either the employee or any other individual.
  • Encouraging employees to report health and safety issues without fear of reprisal.

Academic Programming Faculty and Advisors

It is the responsibility of Faculty, Academic Programming Advisors other Cal Maritime related activities and student clubs to:

  • Develop procedures to ensure effective compliance and support of the Injury and Illness Prevention Program components as it relates to operations under their control. Specific areas of responsibility include student education and training, identification and correction of unsafe conditions, and incident reporting.
  • Develop and maintain written classroom, laboratory, and activity procedures which conform to regulatory, campus and departmental guidelines.
  • Instruct students in the recognition, avoidance, and response to unsafe conditions, including hazards associated with non-routine tasks and emergency operations
  • Permit only those persons qualified by education and training to operate potentially hazardous equipment or use hazardous materials, unless under close supervision.
  • Supervise students in the performance of activities.

Students- Cadets

Students are expected to always adhere to safety practices presented by faculty, technical staff, student assistants, graduate assistants or other authorized individuals.  They must also report potentially hazardous conditions that become known to them. These reports should be made to their supervisors, faculty advisers, Department of Safety and Risk Management, or other responsible parties.

Integrated Safety Management (ISM)

Cal Maritime is committed to having all campus-related work performed safely and in a manner that strives for the highest degree of protection for the Campus Community. To achieve these goals, Cal Maritime implements, the principles of safety through an Integrated Campus Safety Management System (ICSMS).

Simply put, ICSMS applies a plan-do-check-act approach to campus safety management. Five core activities represent the plan-do-check-act approach, and comprise the underlying process for any construction work activity. The five core activities are:

  1. Define the Scope of Work
  2. Analyze the Hazards
  3. Develop and Implement Hazard Controls
  4. Perform Work Within Controls
  5. Provide Feedback and Manage Change

The identification and analysis of workplace hazards is part of the pre-work planning process. The goal of this core activity is to ensure that the hazards associated with construction work activities are clearly understood and appropriately managed. All new campus work activities, changes to existing work or introduction of new equipment or processes (which introduce new hazards or increase the hazard level) need to be reviewed to analyze hazards, identify safety standards/requirements, and establish appropriate controls. Safety conditions and requirements need to be formally established and in place before construction work is initiated.

The campus Job Hazards Analysis (JHA) process is the principle method for achieving this.

Hazard Identification, Risk Assessment &Determining Control Table (HIRAC)

The SRM Hazard Identification, Risk Assessment and Determining Control Table (HIRAC) process is used to identify, assess and risk-rank Cal Maritime campus-related activities in order to ensure that Cal Maritime Campus Safety programs, activities and work controls are appropriately addressing construction risks. The initial HIRAC assessment and risk-ranking of campus-related activities was conducted during the third quarter, AY 2016-2017. The HIRAC assessment will be reviewed annually, when new campus-related activities are introduced that create or modify assessed risks, and when worksite observations or accident/incident experience identify previously unrecognized or incorrectly categorized risks.

Application of Hierarchy of Controls

In developing hazard controls and preparing the Job Hazard Analysis submittal, the campus shall select means and methods to mitigate worker exposure to workplace hazards using the Hierarchy of Controls as specified in the American National Standards Institute (ANSI) Z10-2005 Occupational Health and Safety Management Systems.

The campus shall make a good faith effort to analyze each hazard and identify the appropriate control(s) using the following hierarchy:

  • Elimination or substitution of the hazards where feasible and appropriate;
  • Use of engineering controls where feasible and appropriate;
  • Application of work practices and administrative controls that limit worker exposures; and
  • Provision and use of personal protective equipment

Job Hazards Analysis (JHA)

For the purposes of this section Job Hazard Analysis (JHA) and Job Safety Analysis (JSA) can be used synonymously.  A JHA/JSA can be incorporated into a Pre Task Plan, provided there is a section for employees to review, comment and sign. Core components of the scope of work and relative hazards can be electronically completed ahead of time, provided there is room for current site conditions are able to be readily added as applicable. When the scope or conditions change, the change in work plan should be noted in a different colored pen with employee's initially that they have been briefed on the change.

The Department of Safety and Risk Management will work with individual Departments to develop a master Campus JHA library.

  • Each employee scheduled to work in the activities identified below shall receive safety training in those activities prior to working on them.
  • Subcontractors shall submit a Job Hazards Analysis (JHA) for those construction activities meeting the requirements for performing JHA (see below). The JHA shall be reviewed and authorized to proceed by the Cal Maritime Department of Safety and Risk Management before work commences.
  • Subcontractor shall be responsible for submitting a JHA and work procedures to Cal Maritime Department of Safety and Risk Management for review a minimum of seven days prior to the start of work for most work activities.

JHA Requirements

A JHA shall be written based on the following conditions:

  • Jobs with the highest injury or illness rates
  • Jobs with the potential to cause severe or disabling injuries or illness, even if there is no history of previous accidents
  • Jobs in which one simple human error could lead to a severe accident or injury
  • Jobs that are new to your operation or have undergone changes in processes and procedures
  • Jobs complex enough to require written instructions.

If not otherwise specified in a particular project specification, the JHA shall be performed in accordance with the OSHA 3071.

JHA processes. In general the JHA will include:

  • Description of work phase or activity
  • Identification of potential hazards associated with the activity
  • Address further hazards revealed by supplemental site information (e.g., site characterization data, as-built drawings) provided by the subcontractors construction manager.
  • A list of the Subcontractor's planned controls to mitigate the identified hazards
  • Identification of specialized training required
  • Identification of special permits required
  • Name of the Subcontractor's Competent Person(s) responsible for inspecting the activity and ensuring that all proposed safety measures are followed.

The Departmental of Safety and Risk Management or other competent personnel will conduct in their area, a hazard assessment for each operation, process, or work area where airborne and or bloodborne contaminants may be present in routine operations or during an emergency. 

Each hazard assessment will include:

  • A review of the Material Safety Data Sheets for the hazardous substances used in the area or task that may require respirators.
  • A review of work processes to determine where potential employee exposures may occur due to hazardous vapors, mists, fume, dust, or other types of particulates. 
  • This review is conducted by surveying the workplace, checking accident records, and talking with employees and supervisors.
  • Exposure monitoring to quantify potential hazardous exposures when necessary. 
  • Monitoring records will be kept in the appropriate Coordinator's office for 30 years.

OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials.  The exposure determination is made without regard to the use of personal protective equipment (PPE).  NOTE: Employees are considered to be exposed even if they wear personal protective equipment.  This exposure determination requires the listing of all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequencyThese employees will receive the HBV vaccine.

In addition, OSHA requires a listing of job classifications in which some employees may incur occupational exposure.  Since not all employees in these categories would be expected to incur exposure to blood or other potentially infectious material, tasks or procedures that would cause these employees to have occupational exposure are also listed to clearly identify which employees in these categories are considered to have the potential to be occupationally exposed.  These employees will receive the HBV vaccine post-exposure. 

Our job classifications and associated tasks are as follows:

Our Exposure Control Plan applies to all employees, regardless of whether their position is listed above or not.

Employee Job Classification List for Exposure Determination – shall be based upon an employee's reasonable potential for exposure to blood or any other infectious materials that they may contact during their job duties. Cal/OSHA requires exposure evaluations based on the potential for job-related tasks leading to exposure. The Program at Cal Maritime is designed to cover those who are at a higher risk of exposure and establishes high, moderate, or low risk categories. All other employees will be evaluated and determined on an individual basis by the Chief Staff Physician of the Student Health and Counseling Center and SRM.

The categories and job classifications are:

Category 1, High Risk involves procedures or jobs with inherent potential for contact with blood, body fluids, tissues, mucous membranes, or skin contact that could possibly transmit the HBV, HIV or other bloodborne pathogens and includes these Job Classifications:

  • Physician
  • Radiological Technologist
  • Registered Nurse
  • Nurse Practitioner
  • Clinical Laboratory Tech
  • Clinical Aids

Category 2, Moderate Risk - This category has been established for employees who do not work in situations that routinely (day to day) involve contact with infectious materials.

However, a potential for exposure exists. It includes these Job Classifications:

  • Custodians (assigned to Health Center)
  • Police Officers and Investigators
  • Physical Therapist
  • Athletic Trainers (Students and Coaches
  • Lifeguards

Category 3, Minimal Risk - This category involves no exposure to blood, body fluids or tissues such as are described in category 1. However, exposure is possible and it includes these Job Classifications:

  • First Aid and CPR Responders
  • Housing Personnel
  • All Other Custodians
  • SRM Personnel

Universal Precautions

All blood and blood products will be perceived as infectious regardless of the status of the source individual. The procedures for handling human body fluids shall be developed by each supervisor to ensure safe use or analysis of these fluids. These procedures must specify handling, transportation, storage, and analytical protocols and shall be maintained with the Program.

The routes of transmission for occupational exposure are:

  • Puncture of the skin with a contaminated object;
  • Contact with broken skin; and
  • Contact with mucous membranes of the eye, nose, or mouth.

Work Practice Controls and Compliance Methods

Accidents are not the only instances where blood and other potentially infectious body fluids may be encountered.  Sometimes employees encounter less obvious hazards while performing routine cleaning or maintenance tasks.  These hazards are just as dangerous as accident situations. 

Engineering and work practices will be used, reevaluated and revised on a regular basis to ensure their effectiveness. This should eliminate or reduce employee occupational exposures. Whenever practical, these engineering controls shall be used as a first line of defense against exposure to bloodborne pathogens. In areas where exposure to bloodborne pathogens may occur, special procedures will be developed by the lab manager or supervisor to insure safe handling of these potentially infectious fluids or media. The procedures will include proper handling, storage, transportation, and analytical procedures and will be maintained at each work location by the Supervisor.

These controls include:

  • No foods or drink will be stored (including refrigerators, freezers, shelves, cabinets or on countertops) or consumed in areas where bloodborne pathogens may be present.
  • Contaminated needles or sharps will not be recapped, bent, or broken unless the supervisor can demonstrate that no alternative is feasible or that such action is required by a specific medical procedure. Such bending, recapping, or needle removal must be accomplished through the use of a mechanical device or a one-handed technique.
  • Immediately, or as soon as possible after use, all potentially contaminated sharps will be placed in a puncture proof, labeled, leakproof container and disposed of by methods outlined the Biosafety Manual of the Injury and Illness Prevention Program.
  • All potentially infectious protruding objects will be placed in puncture resistant containers (a box or corrugated container consistent with those described in the Biosafety Manual).
  • After use, or as soon as possible, reusable sharps will be placed in the appropriate containers for sterilization or reprocessing.
  • The lab supervisor or manager is responsible for ensuring that employees and students wear the proper PPE.
  • Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
  • All procedures must minimize splashing, spraying, spattering, and generation of droplets of infectious substances.
  • Appropriate respiratory protection will be used based on the hazard.
  • Departments shall provide hand washing facilities that are readily accessible to employees. When facilities are not available, employees shall be provided either with an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic wipes. When antiseptic hand cleansers or wipes are used, hands shall be washed with soap and running water as soon as feasible.
  • Employees shall wash their hands immediately, or as soon as possible, after the removal of gloves or other PPE.
  • No eating, drinking, smoking, applying cosmetics, or handling contact lenses in work areas where exposure potential exists.
  • Mechanical devices that isolate or remove the hazard from the worker will be used whenever possible.  These devices include:
    • Proper disposal containers
    • Sharps containers
    • Red bio-hazard bags
    • Biohazard burn buckets
    • Eyewash stations
    • Hand washing facilities and antimicrobial hand sanitizers that are easily accessible
    • Germicidal surface cleaner
    • Body-fluid disposal kits (Company vehicles, first aid kits, and emergency response bags)

PPE Will be made available to employees and students upon entry into laboratory  and  work areas where infectious materials may be present. This equipment will be removed immediately upon leaving these work areas and placed in the appropriate receptacle for storage, washing, decontamination, or disposal. This equipment includes

Guidelines for Use of PPE

  • PPE shall be provided where necessary by the department at no cost to the employee.
  • Departments shall train and ensure their employees properly use the PPE available.
  • The department must clean, launder, and dispose of PPE at no cost to the employee.
  • If a garment is penetrated by blood or other potentially infectious material, the garment shall be removed immediately or as soon as feasible.
  • All PPE shall be removed prior to leaving the work area.
  • When removed, PPE shall be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.
  • Employees or students failing to utilize required PPE are subject to disciplinary action as deemed appropriate by the department.

Gloves –

  • Disposable gloves will be worn when the employee or student has the potential for skin contact with infectious materials. Disposable gloves shall be properly disposed if visibly soiled, torn, or damaged. They will not be washed or disinfected for re-use. Gloves are not to be removed or worn outside the work area (hypoallergenic gloves shall be provided to personnel who are allergic to the gloves normally provided). Non- disposable gloves used in the handling of potentially infectious material must be washed thoroughly with soap and water prior to removing. Handwashing must follow removal of all gloves.

Masks / Eye Protection / Face Shields –

  • Will be worn singularly or in combination as guidelines specify. They will be worn when the potential exists for spattering, spraying, splashing droplets or aerosols of blood or any other potentially infectious materials may be present. This applies when the employee or students' eyes, nose, or mouth are potentially exposed to contamination.
  • Aprons / Gowns / Lab Coats / Disposable Shoe Covers - will be worn based on the potential for occupational exposure in addition to similar garments that provide effective barriers against blood or any other infectious materials. Shoe and/or head covers will be worn as needed or as required by protocol.

Glove Removal

As recommended by the American Heart Association

  • Grip one glove on the outside of the glove near the cuff and peel it down until it comes off inside out.
  • Cup it with your other (gloved) hand.
  • Place 2 fingers of your bare hand inside the cuff of the glove that is still on your hand.
  • Peel that glove off so that it comes off "inside out" with the first glove inside it.
  • Dispose of gloves in the trash.
  • Hands must be washed immediately, or as soon as feasible, after removal of gloves.

Cleaning and Disinfecting Contaminated Equipment

Disinfectants and/or germicides shall be applied  to working area surfaces to sterilize them. A written policy and schedule which outlines methods for decontamination and disinfection shall be implemented in these work areas where bloodborne pathogens may be present. All equipment and working surfaces shall be disinfected routinely after use of blood or any other potentially infectious materials.

  • Working surfaces and equipment shall be cleaned after completion of work procedures, when they are overtly contaminated, immediately after a spill of potentially infectious materials, routinely after the end of the work shift, and prior to maintenance or service.
  • Surfaces where infectious materials are used shall be protected with coverings such as imperviously-backed absorbent paper plastic wrap, or aluminum  foil.  These  coverings  shall  be changed at the end of every shift or as necessary.
  • Broken glassware which may potentially be contaminated shall be picked up by tongs, forceps, broom, dust pan, etc. At no time will employees pick up potentially contaminated broken glass with their bare hands. PPE shall be worn during the cleanup (example: goggles, face mask, and cut resistant gloves).
  • All containers, bins, pails, cans, or similar receptacles intended for use in disposal of these waste will have a lid or top on the container. These containers will be collected on a daily basis or when the container becomes full. The reusable containers will be inspected, cleaned, and disinfected routinely, as soon as possible, or after visible contamination.
  • Reusable items that may be potentially infectious will be decontaminated before washing or reprocessing.

Potentially contaminated laundry shall be collected from employees and cleaned routinely. Employees who normally generate potentially contaminated garments shall be informed of the location and specific container for the garments. These garments will not be rinsed or sorted at the location of their removal. The employees who collect, wear, or process these garments shall wear the proper PPE (gloves, lab coats, etc.), and receive bloodborne pathogen training. The containers in which these garments are collected will be labeled as biohazardous soiled laundry. The containers must be closeable, leak proof or lined with leak proof bags, and color coded.

Only employees who have been designated (employees who have job descriptions that require they be trained/certified in CPR/AED/First Aid) may administer first aid or CPR.  Anyone providing first aid where blood or bodily fluids are present must wear ASTM – approved medical gloves and a mask/eye shield.   A number of employees that are CPR and first aid trained or may be put into a position where they might assist employees or students with minor injuries may come into contact with blood or other infectious materials. While pre-exposure precautions do not apply, precautions must be taken by these individuals to avoid exposure. Cal Maritime employees must use the following guidelines to avoid possible exposure:

  • All departments should have, as part of their required first aid supplies, several pair of disposable gloves to use as outlined. SRM will supply these gloves if needed.
  • Serious injuries involving loss of blood should be reported immediately to Cal Maritime Police at 911 from a campus or cell phone.
  • Contact with the blood of an injured person should be avoided. For non-serious first aid injuries, allow the injured person to treat themselves or assist by transporting to the Health Center.
    • If contact and exposure is unavoidable, wear protective gloves
    • If blood or body fluid exposure occurs, a Report of Employee Injury Form must be filed with Risk Management and the employee's supervisor and a Post Exposure to Bloodborne Pathogens Form filled out and submitted SRM. Contact your supervisor, Department Administrator, Safety Coordinator, or call SRM at  ext. 1076.
  • Do not attempt to clean up any of the spilled blood, if present. This is considered biohazardous medical waste and must be cleaned up and disposed of according to waste regulations. Notify the Facilities Service Center at ext. 1120.

Disposal of Contaminated and Uncontaminated Sharps

  • Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are closeable, puncture resistant, leak proof on sides and bottom, and properly labeled.
  • Containers for sharps shall be easily accessible to personnel and located as close as possible to the area where sharps are used or can be reasonably anticipated to be found.
  • Containers shall be kept in an upright position throughout use and replaced when 3/4 full.
  • When containers are moved, they must be closed to prevent spillage or protrusion.
  • If leakage is possible, a secondary container must be used to prevent leakage during transport and handling. The secondary container must be properly labeled to identify the contents.

Regulated Medical Waste Disposal

Regulated medical waste must be placed in containers that are collapsible and constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, and shipping.

  • All containers must be labeled with the contents and a biohazard symbol.
  • Prior to removal from the area of use, the container must be closed to prevent spillage or protrusion.
  • If a secondary container is used to prevent spillage, it must also be closeable, labeled, and closed prior to removal.

Containers used for the containment and/or transport of medical waste must be leak resistant, have tight fitting covers, and kept clean and in good repair. The container must be red and  labeled  with  the  words  "Biohazard  Waste",  or  with  the international biohazard symbol and the word "Biohazard" on the lid and sides so as to be visible from any lateral direction

Contaminated/Non-Contaminated Protruding Objects

  • These are objects that may not normally be treated as sharps but have the potential of scratching, cutting, or puncturing the skin or container without special procedures and considerations for handling them. This places a special concern for those who collect and transport these items as waste haulers. These objects include but are not limited to needles, razor blades, scalpels, broken glass and/or plastic, sharp edged metals or wire, glass or plastic pipettes, capillary tubes, plastic or glass rods, etc. Protruding objects that are potentially infectious are to be treated as contaminated sharps and should be disposed of in accordance with the procedures outlined in the Biosafety Manual. All other protruding objects are to be disposed of in a puncture proof container that can be taped closed and placed into the regular trash.

Hepatitis B Vaccinations

HBV vaccinations will be made available to all employees in categories 1 and 2 (high and moderate) who are occupationally exposed to infectious materials at no cost. Each identified employee will receive information on the HBV vaccine, including information on its efficacy, safety, method of administration, and the benefits of being vaccinated.

The following provisions apply:

  • HBV vaccinations must be made available to all employees within ten working days of initial assignment unless the employee has previously received vaccination, antibody testing has shown the employee to be immune, or unless contraindicated for medical reasons.
  • Employees must receive training in bloodborne pathogens.
  • If an employee initially declines the HBV vaccination he or she must sign the HBV Vaccine Declination Form. If that employee, at a later date, decides to accept the HBV vaccination, it will be provided.
  • SRM with collaborate with HR to coordinate and schedule all HBV vaccinations to be given employees at either the designated treating facility.
  • Three months following the vaccination series, a test for anti- bodies will be conducted
  • If a routine booster dose of HBV is recommended by the U.S. Public Health Service at a future date, such booster will be made available to employees.
  • Unvaccinated first aid providers will be  offered  HBV vaccinations following exposure as outlined.
  •  It is not required to offer pre-exposure vaccinations for voluntary first aid providers if the following conditions exist:
    • Rendering first aid is not the primary job assignment.
    • The employee does not render first aid on a regular basis at a location where injured employees regularly go for assistance.

Post Exposure Evaluation and Follow-up

After a report of an exposure incident, the following procedures must be followed:

  • The exposure incident must be reported to the Supervisor, Department Administrator, or Department Safety Coordinator before the end of the work day in which the exposure occurred. A Report of Employee Injury Form must be filed with Risk Management and a Post Exposure to Bloodborne Pathogens Form must be immediately.
  • Cal Maritime shall make available to the employee a confidential medical evaluation and follow-up.
  • A full HBV vaccination series will be made available within 24 hours to those first aid providers that have not received the pre- exposure series.
  • Documentation will be made of the routes of exposure and the circumstances under which the exposure incident occurred.
  • Identification of the source individual must be made, if possible. The source individual's blood must be tested if consent can be obtained. Source testing is not needed if it is already known the individual is infected with HBV or HIV. Results of the test must be made available to the exposed employee.
  • The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained. If the employee consents to blood collections, but does not give consent for testing, the sample must be preserved for 90 days. The employee may elect, during that time, for testing to be done. Additional testing and collection will be made available as recommended by the U.S. Public Health Service.

Information provided to the attending physician shall include:

  • A copy of Appendix A, CCR Title 8, Section5193
  • Description of affected employee's job duties and history regarding the occupational exposure (completed Post Exposure to Bloodborne Pathogen Form).
  • Documentation of the route of exposure and circumstances under which exposure occurred.
  • Results of the source individual's blood testing, if available.
  • All medical records relevant to the appropriate treatment of the employee including vaccination status.

Healthcare Professional's Written Opinion

The attending physician shall provide documentation to Cal Maritime of the following information within 15 days of the evaluation:

  • An opinion whether or not an HBV vaccine is indicated and the series has been initiated.
  • That the employee has been informed of the results of the evaluation.
  • That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

Labels and Signs

Cal/OSHA requires communication to employees who may come in contact with bloodborne pathogens. It may include material safety data sheets, labels, warning signs, and training.

Warning Signs

Warning signs will be posted on the doors outside of the labs where potentially infectious materials are used. They will provide the following information:

  • The international symbol for biohazard.
  • The name of the specific biohazardous materials used in the location.
  • The special requirements for PPE and other laboratory procedures.
  • The name and telephone number of the principle investigator, lab supervisor, or other responsible person.
  • Warning Labels - Labels shall be affixed to all containers used to collect, store, or transport potentially infectious materials (sharps containers, bags, boxes, refrigerators, freezers, waste cans, and buckets). These labels shall include the universal legend for biohazard or a label that states "biohazardous waste." The label shall be fluorescent orange or orange-red with lettering or symbols in a contrasting color. These labels will be affixed to a container in a manner as to prevent their removal (for more information reference the Biosafety Manual).

Sewage Spills and Cleanup

All Sewage Overflows

Cal Maritime personnel are to immediately inform the Department of Safety and Risk Management whenever a sewage spill of any size occurs as well as to obtain property damage, incident, or injury reporting packets.

Notify the SRM immediately if the spill:

  • May enter or flow into surface waters (streams, ponds, lakes, wetlands) or storm drains.
  • Is in a public area where there is a potential for human exposure.
  • Is in a food service or food preparation area.

Surface Waters and Storm Drains

Properly trained maintenance personnel should attempt to prevent the spill from entering surface waters or storms drains by containing or diverting the flow.

The SRM t is responsible for contacting the appropriate agency if sewage from a spill actually enters or flows into surface waters or storm drains.

Cleanup Personnel

Personnel who perform sewage spill cleanup must be properly trained in accordance with the Hazard Control Plan for Bloodborne Pathogens and use good personal hygiene practices.  Personal protective equipment shall include:

  • Gloves
  • Safety goggles
  • Face shield
  • Disposable suit
  • Boots or disposable shoe covers

Contaminated non-disposable clothing should be bagged in a yellow biohazard bag, labeled as to the type of contaminant, and sent to the Laundry.

Tools for cleanup include shovels, buckets, hose, shop vac, and disinfectant.

Cleanup personnel must isolate the spill and post signage to ensure that individuals not involved in the cleanup and disinfection of the sewage spill remain out of the area until contamination has been removed and the area disinfected.

Sewage Disposal

Cleanup personnel are to use the sanitary sewer system (toilet, sewer manhole, or floor drain) to dispose of sewage.  Sewage is NOT to be disposed of in storm drains, gutters, ditches, surface waters, or any other location where it could enter surface waters, cause groundwater contamination, or result in human exposure.

To comply with proper procedures for the disposal of contaminated materials, the following items are provided at each project:

  • ASTM – approved latex/nitrile gloves
  • Red "Sharps" containers
  • Red biohazard bags
  • Germicidal surface cleaner
  • Antimicrobial skin sanitizer
  • Antibacterial soap

Only trained staff will handle the following situations:

  • Broken Glass ~ Drinking Glasses, Bottles, Light Bulbs, etc.
    • PPE ~ broken glass container, gloves, damp cleaning cloth, dustpan, and broom.
    • Procedure:
      • Take broken glass container to area.
      • Put on gloves.
      • Use dustpan and broom to sweep area.  Place contents in the broken glass container.
      • Use damp cloth to wipe floor area to remove all slivers of glass.
      • Dispose of cloth in plastic bag.
      • Close lid of container and return to linen room.
      • After removal and proper decontamination/disposal of PPE, employees wash their hands and any other potentially contaminated skin area immediately, or as soon as possible, with soap and water.  "Rinse" sink while washing hands.  Spray sink with virucidal disinfectant.
  • Dead Rodent
    • PPE ~ gloves, goggles, virucidal disinfectant two small plastic bags.
    • Procedure:
      • Do Not Vacuum.
      • Close all windows.
      • Put on gloves and goggles.
      • Spray rodent/droppings with virucidal disinfectant; allow to remain for 10 minutes.
      • Place rodent/droppings in bag #1; place bag #1 in bag #2; tie securely.
      • Dispose of bags in garbage.
      • After removal and proper decontamination/disposal of PPE, employees wash their hands and any other potentially contaminated skin area immediately, or as soon as possible, with soap and water.  "Rinse" sink while washing hands.  Spray sink with virucidal disinfectant.
  • Rodent Nest
    • Housekeeping cleans up one rodent and droppings. 
    • Maintenance is responsible for taking care of nests and/or multiple rodent bodies.
  • HEPA filtered vacuum cleaners used for the clean up of particulates. 
  • This vacuum is designed to remove impurities both in the air and on surfaces. 
  • When using the HEPA vacuum, the surface must be dry before the HEPA vacuum is used, as this is not a wet/dry vacuum. 
  • See  Department Manager for the location of the HEPA vacuum and instructions on its use.
  • Syringe or Needle
    • PPE ~ Gloves, "Sharps" container, and tongs.
    • Procedure:
      • Put on gloves.
      • Bring "Sharps" container to the object.
      • Use tweezers (located in the first aid kit) to place the object in the container.
      • After removal and proper decontamination/disposal of PPE, employees wash their hands and any other potentially contaminated skin area immediately, or as soon as possible, with soap and water.  "Rinse" sink while washing hands.  Spray sink with virucidal disinfectant.
      • Return "Sharps" container.
  • Body Fluids on Linen or Terry Cloth
    • PPE ~ Gloves, veridical disinfectant, biohazard bag.
    • Procedure:
      • Put on gloves.
      • All soiled linen is removed and placed in a biohazard bag.
      • Write on the bag (black marker) what the contaminant is (urine, vomit, etc.), your location, your department and the date.
      • Tie bag shut and place in the closest linen room.  Notify the Linen Supply Agents that there is an item that needs to be sent with the dirty laundry.
      • After removal and proper decontamination/disposal of PPE, employees wash their hands and any other potentially contaminated skin area immediately, or as soon as possible, with soap and water.  "Rinse" sink while washing hands.  Spray sink with virucidal disinfectant.
  • Body Fluids on Hard Surfaces
    • PPE ~ Gloves, yellow biohazard bag, virucidal disinfectant and cleaning cloth.
    • Procedure:
      • Put on gloves.
      • Use cleaning cloth to wipe area without spreading.
      • Spray area with virucidal disinfectant and wipe again.  Put cloth in biohazard bag.
      • Spray and wipe again until surface is completely clean.
      • Place all used cloths in yellow bag.
      • Label the bag (black marker) what the contaminant is, your location, and your department.
      • After removal and proper decontamination/disposal of PPE, employees wash their hands and any other potentially contaminated skin area immediately, or as soon as possible, with soap and water.  "Rinse" sink while washing hands.  Spray sink with virucidal disinfectant.

Any time gloves from the first aid kit are not available; a pair of regulation housekeeping gloves can be used.  Gloves should be disposed of according to the guidelines listed above.

Personal protective equipment is located in the following areas at this facility:

  • At the entrance to the facility
  • In the small wash-deck area
  • At the tunnel load conveyor
  • In the maintenance work area
  • In the custodial closet
  • In the laundry trucks
  • Next to the receiver's desk near the sorter

Hand washing facilities are located in the following areas:

  • Men's restroom
  • Women's restroom
  • Laundry Services room
  • Uniform room bathroom
  • Breakroom
  • On locations (for truck drivers)

An exposure incident is defined as a specific eye, mouth, or other mucous membrane, non-intact skin, or parenteral contact with blood or other possible infectious materials, resulting from an employee performing their duties.  When an employee has an exposure incident while on duty, it should be immediately reported to department management as well as the department of safety and risk management.  The employee will be offered a post-exposure evaluation and follow-up in accordance with the OSHA Standard.  The follow-up will be coordinated by the Human Resources Department.

The follow-up will include documentation of the route of exposure and the circumstances related to the incident and, if possible, the identification and status of the source individual.  The source individual's blood will be tested for HIV-1 and HBV after the individual's consent is obtained.  The source individual's test results will be made available to the employee.

If deemed necessary by the licensed healthcare professional, the exposed employee will be offered the HBV tier vaccine and vaccination at the expense of Cal Maritime within 24 hours.   Prior to receiving the vaccination, the employee will be tested for HIV to set a baseline for possible future complications.

Cal Maritime will ensure that all medical evaluations and procedures, including the vaccine series and post-exposure evaluation, follow-up and any protective and preventative treatment are:

  • Performed by or under the supervision of a licensed physician or other licensed healthcare professional.
  • Provided in accordance with current recommendations of the U.S. Public Health Service at the time the evaluations and procedures take place.

These provisions will apply unless:

  • The employee has previously received the complete HBV vaccination series;
  • Antibody testing has revealed that the employee is immune; or
  • The vaccine is contraindicated for medical reasons.

No HBV vaccine booster will be provided at this time; however, if it is required at a later date, the vaccine will be provided at no cost to the employee.

The healthcare professional evaluating an incident requires the following:

  • A copy of the Bloodborne Pathogens Standard.
  • A description of the employee's duties as related to the exposure incident.
  • Documentation of the route(s) and circumstances of the exposure incident.
  • Results of the source individual's blood testing, if available.
  • All medical records, which are the employer's responsibility, relevant to the appropriate treatment of the employee, including vaccination status.

The employer shall provide the exposed employee with a copy of the evaluating healthcare professional's written opinion within 15 days.

All medical and training records for exposed employees will be made available to OSHA and NIOSH if requested.  Employee medical records and training records will be made available to the employee or their representatives upon a written request from the employee.  Counseling or evaluation of reported illness will be made available to the employee upon written request.  If Cal Maritime ceases to do business and there is no successor employer to receive and retain records, Cal Maritime will notify NIOSH at least 3 months prior to their dismissal, and the records will be transmitted to NIOSH, if requested by that agency.

When you are informed that an employee has experienced an "exposure incident" while working, please immediately take all of the following steps:

  • Speak with the employee and let him or her know that Cal Maritime's Exposure Control Program for Bloodborne Pathogens includes an offer to the employee of confidential post-exposure medical evaluation and follow-up.
  • Print the Post-Exposure Medical Evaluation Consent/Waiver Form and provide it to the employee.  The employee must indicate in writing his/her consent or waiver of the medical evaluation.  If the employee has sought medical treatment before providing this form, that's fine, but he or she must still complete the form for you at the earliest possible time.
  • Make a copy of the Waiver form and give it to the employee; have them seek assistance at the clinic or doctor immediately.  (Whenever possible to do so safely, provide needle or other exposure item to the clinic as well.)  Please call the clinic or doctor and notify them that an employee is on the way and has experienced an exposure incident at work.
  • Contact SRM and provide the following:
    • The employee's name
    • The circumstances of the exposure incident
    • Whether the employee is seeking treatment, and where the employee is seeking treatment
    • Whether the source individual (the person who's blood/body fluids the employee was exposed to) is known
    • If the source individual is known, provide that information as well to SRM.
  • After the medical visit is completed, speak with the employee about completing a work-related injury packet; an exposure incident at work can be considered a work injury and may be covered by Workers' Compensation.  As always, the employee cannot be forced to complete an injury packet, but if he or she refuses, complete the supervisor's report and note that the employee was offered an injury report and declined.  Send the completed injury report, or supervisor's report if the employee refuses to complete report, to SRM Management.
  • Send the employee's original Post-Exposure Medical Evaluation Consent/Waiver Form to SRM Management.

Note: remember that this type of incident shall be kept confidential – involve only the minimum number of people required, and ensure HIPPA protocols are in place.

Effective dissemination of safety information lies at the very heart of a successful Injury and Illness Prevention Program.  It is essential to provide training for employees concerning general safe work practices as well as specific instruction with respect to hazards unique to each employee's job assignment.

Training content is determined by the Department of Safety and Risk Management, as well as Department Management which is based upon observed hazards, type of equipment, Department need, and work requirements.

  • Providing training from within the department, or
  • Safety Training provided by SRM, or
  • A training provider outside the University.
    • Note: All outside trainer venders are to be reviewed and content approved by SRM.

Training shall be provided to each affected employee:

  • Before the employee is first assigned duties that require him or her to serve as a first aid responder.

Before there is a change in assigned duties.

  • Whenever there is a change first aid procedures or operations.
  • Whenever the company has reason to believe that there are deviations from the first aid response procedures required by this instruction or inadequacies in the employee's knowledge or use of these procedures.

The training shall establish employee proficiency in the duties required by this instruction and shall introduce new or revised procedures, as necessary, for compliance with this instruction or when future revisions occur.

Cal Maritime shall certify that the training required by this section has been accomplished. The certification shall contain each employee's name, the signatures or initials of the trainers, and the dates of training. The certification shall be available for inspection by employees and their authorized representatives.

Training Information –

Training is provided to employees at the time of initial task assignment where occupational exposure may take place and annually thereafter.  Training is recorded on the employee's Safety Training Checklist.  Additional training is provided when changes such as modification of tasks/procedures or institution of new tasks/procedures affect the employee's occupational exposure.  The additional training may be limited to addressing the new exposures created.

The training program contains, at a minimum, the following elements:

Refer to Cal/OSHA Safety & Health Training and Instruction Requirements as outlined in Appendix C of the Injury Illness Prevention Program.

  • An accessible copy of the regulatory text of the Bloodborne Pathogens Standard and an explanation of its contents.
  • Information on Cal Maritime Exposure Control Plan for Bloodborne Pathogens and the means by which the employee can obtain a copy of the written Plan.
  • Information on the epidemic nature and symptoms of bloodborne/airborne diseases.
  • Information on the modes of transmission of bloodborne /airborne diseases.
  • Information on the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
  • Information on the use and limitations of methods that will prevent or reduce exposure, including appropriate engineering controls, work practices, and personal protective equipment.
  • Information on the types and locations of personal protective equipment, as well as the proper use, handling, removal, decontamination, and disposal procedures pertaining to personal protective equipment.
  • Information on the HBV vaccine, including information on effectiveness, safety, and method of administration, as well as, the benefits of being vaccinated.  When the HBV vaccine is determined necessary, it will be offered to employees at the expense of Cal Maritime.
  • Information on the appropriate actions to take and people to contact in an emergency involving blood or other potentially infectious materials.
  • Information on the procedure to be followed if an exposure incident occurs, including the method of reporting the incident.
  • Information on the post-exposure evaluation and follow-up that Cal Maritime will provide for the employee following an exposure incident.
  • Information on the signs and labels required.
  • An opportunity for interactive questions and answers with the people conducting the training session.

Essential records, including those legally required for Workers' Compensation, insurance audits and government inspections will be maintained for as long as required.  Individual Departments and/or Colleges will also keep records of steps taken to establish and maintain the Injury and Illness Prevention Program.  

They must include:

  • Records of scheduled and periodic inspections to identify unsafe conditions and work practices.  The documentation includes the name of the person(s) conducting the inspection, the unsafe conditions and work practices identified, and the corrective action(s) taken.  These records will be maintained for at least three years.
  • Training records will be kept in each department and copies will be forwarded to the Department of Safety and Risk Management. Training records in electronic and hard copy format shall be prepared and maintained by SRM or the safety coordinator of the department conducting the training.

Departments must maintain the following records as part of this Program.

  • Employee training records
    • The dates for the training session.
    • The contents, outline, and summary of the training.
    • The names and qualifications of the trainer.
    • The names and job titles of all attendees.
  • Specialized SOPs
  • Manufacturer specifications/manuals
  • Maintenance/service records

Documentation of health and safety training for each employee. Specifically, employee name or other identifier, training dates, type(s) of training and the name of the training provider will be included. Records will be retained for at least three years.  Standard forms for maintaining this information can be obtained from the Department of Safety and Risk Management.

  • Medical Records –

Shall be confidential and will not be disclosed to any person except where regulation requires. Each record wil be maintained for a period of at least 30 years and will include the following information:

  • The employee's full name and social security number.
  • A copy of the HBV vaccination record or declination form.
  • A  written  record  of  all  medical  evaluations,  results, recommendations, and follow-ups.
  • The attending physician's written evaluation.
  • Copies of all other information provided the healthcare professional.
  • Records Availability

Will comply with CCR Title 8, Section 5193. Employees can access their training records through the Employee Training Center.

  • Transfer of Records - shall comply with the requirements of CCR Title 8, Section 3204.
  • Contract Services - Contractors with employees exposed to bloodborne pathogens must have their own Bloodborne Pathogens Program and job specific guidelines for work at Cal Maritime. The contractor must provide a written program to the Director of SRM prior to start of work.

The Code of Federal Regulations, 29CFR 1910.1030 and the California Code of Regulations (CCR), Title 8, Section 5193, (See Appendix A) requires employers to develop and implement an exposure control plan for their employees. The regulatory agency for this standard is the California Division of Occupational Safety and Health, Department of Industrial Relations (Cal/OSHA).


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