institutional policies

Bloodborne Pathogens Control Policy

Bloodborne Pathogens Control Policy

The following Bloodborne Pathogens Control Policy has been prepared in accordance with the OSHA Bloodborne Pathogens standard, 28 CFR 1910.1030.

I. Policy Statement

It is the policy of this institution to safeguard, to the highest degree possible, College employees and the public who come into contact with people who are known to have or suspected of having a communicable disease without sacrificing services to the College or individual students.

It is also the intent of this policy to train, educate, and establish guidelines and procedures for employees to reduce the risk associated with exposure to blood and/or bodily fluids.

This policy applies to all Macomb Community College personnel that may come into contact with blood or other potentially infectious materials in the performance of job duties.

This policy will be reviewed and updated on an annual basis. The review shall include changing technologies and consideration of appropriate commercially available and effective medical devices designed to reduce or eliminate exposure to bloodborne pathogens.

II. Discussion

It is predictable that at some point in time a College employee will come into contact with a person who has an infectious disease. College personnel, when dealing with blood, items stained with blood or other bodily fluids, and persons in high-risk groups, should exercise extreme caution. The procedures outlined in this policy shall be used to reduce the risk of exposure.

III. Training and Education

A trained professional will give the initial introductory training class. It is mandatory that all College employees who could be exposed to blood or other bodily fluids attend. At this time the College has determined that the following groups of employees/departments have the potential to be exposed to blood or other bodily fluids:

  1. College Police
  2. Plant Operations
  3. Health and Human Services faculty
  4. Science faculty
  5. Laboratory supervisors and lab aides

Each employee will receive a copy of the Bloodborne Pathogens Standard. It is expected that the employee will review it and know its requirements.
Annual training will be provided. Additional training will be provided when changes in tasks or procedures affect the employee's occupational exposure.

The training program will address all the elements listed in the Standard. Records of the training will be kept as required by the Standard. Training procedures and content will be reviewed and updated annually.

IV. Procedures


  1. An exposure occurs when a person's blood or bodily fluid transfers to another person's blood stream. Exposure can occur through needle sticks, human bites or cuts, sores or abrasions on the skin, or splashes into the eyes, nose or mouth. Examples of bodily fluids include blood, saliva, tears, vomit, semen, urine, or stool.
  2. One of the above conditions must be met for an actual exposure.

An employee who believes they have been exposed to an infectious disease:

  1. Shall thoroughly wash the affected area with soap and hot water if direct contact was made.
  2. Shall gather information about the person involved. The employee should get the person's name, date of birth, any medical information legally available, and the location of the person. The employee should provide information that led the employee to believe the person has an infectious disease. This information may not be disclosed under the Freedom of Information Act.
  3. Shall immediately contact his/her supervisor.
  4. Shall file a timely written report with the Department Administrator.

    The supervisor may contact the County Public Health Department, advise the staff of the exposure, and follow the Health Department instructions, or

    The supervisor may contact Concentra Medical Center or the closest hospital emergency room, if necessary, advise the doctor of the exposure, and follow the doctor's instructions.

Blood Test

When a supervisor has been advised that an employee may have been exposed to a communicable disease, the supervisor may ask the suspected carrier to voluntarily submit to a blood test. The blood test shall be administered by medical personnel.

V. Engineering and Work Practice Controls

The following precautions should be observed:

Universal Precautions
Effective immediately, universal precautions will be practiced in all work areas to prevent contact with blood or other potentially infectious materials. If it is difficult or impossible to differentiate between bodily fluids, all materials contaminated with bodily fluids shall be considered potentially infectious. All employees will be trained in the concept and application of universal precautions.

Engineering and Work Practice Controls
The following practices will be instituted as a primary means of eliminating or reducing employee exposure:

  1. Personal protective equipment, such as gloves, goggles, and face shields, will be supplied and used.
  2. Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure effectiveness.
  3. Handwashing facilities will be readily accessible. If this isn't feasible, antiseptic hand cleaners and/or towelettes will be provided. Handwashing is required, including after removing gloves, after exposure to blood or other infectious material.
  4. Procedures to minimize needle sticks will be implemented according to the Standard. Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless there is no feasible alternative or it is required by a specific medical or dental procedure. Bending, recapping or needle removal must be accomplished by mechanical means or a one-handed technique. Immediately or as soon as possible contaminated reusable sharps shall be placed in appropriate containers until properly processed. The containers shall be puncture resistant, labeled or color-coded in accordance with the Standard, leakproof on the sides and bottom. Contaminated reusable sharps shall not be stored or processed in a manner that requires an employee to reach into the storage container. Written procedures shall be developed and enforced in each department.
  5. Extreme care will be used when examining or cleaning suspected areas. Procedures to be performed will minimize splashing, spraying, spattering, or the generation of droplets of contaminated substances.
  6. Open wounds or cuts will be bandaged to avoid direct contact with contaminated bodily fluids. Bandages will be changed if they become wet or soiled.
  7. Eating, drinking, smoking or applying makeup in areas of potential exposure is prohibited. Food and drink is not to be kept where blood or potentially infectious substances could be found.
  8. Employees who have a suppressed immune system should avoid contact with areas where bodily fluids are present or with persons who have infectious diseases.

VI. Handling and Disposal Precautions

  • Persons working for extended periods of time in areas where blood or other bodily fluids have been shed should wear anti-contamination clothing such as suits, masks, boot covers and gloves.
  • All College personnel shall adhere to a precise regimen when handling, processing and storing potentially infectious disease-contaminated materials and property.
  • Clothing known to be contaminated with a suspected infectious disease is to be clearly labeled and placed in a specified area.
  • Protective disposable gloves will be furnished to personnel handling contaminated materials.
  • All material and property for disposal shall be put in sealed red "BIO HAZARD" plastic bags and placed in a conspicuously labeled contamination area. All materials shall be double bagged. A Hazardous Materials/Environmental Technician will be notified and will dispose of the materials properly.

VII. Vehicle Maintenance

Upon discovery of blood or bodily fluids in a vehicle, a supervisor shall be notified and the vehicle taken or towed to the service center as soon as possible. Service personnel shall follow the appropriate procedures to disinfect the vehicle. After arriving at the service center and while awaiting disinfection, the affected vehicle shall be identified by the posting of a "Contaminated Area" sign. The following procedure shall be used to disinfect the vehicle:

  1. Protective disposable gloves shall be worn during all phases of disinfection.
  2. Any excess blood or bodily fluids should first be wiped up with the approved disposable, absorbent materials. Absorbent materials should immediately be bagged and placed in the designated red "BIO HAZARD" waste bag and stored in the appropriate contamination area.
  3. A broad spectrum activity virucidal-germicidal solution shall be prepared according to prescribed standards.

For small items or equipment, wash the item with the germicidal solution and hot water then rinse thoroughly. Soak the item in a solution of water and household bleach for 10 to 15 minutes. Use a concentration of 1 to 1 ½ cups of bleach for each gallon of water. Rinse with water and air dry.

For large items or areas, disinfect with the bleach and water solution and then clean with soap or detergent.

All disposable, contaminated cleaning items shall be placed in red "BIO HAZARD" plastic bags and placed in the designated contaminated item receptacle.

After cleaning the vehicle, the "Contaminated Area" sign shall be disinfected.

The interior of all College vehicles shall be periodically cleaned with the approved virucidal-germicidal solution.

VIII. Contamination

A. Material or Property Contamination
When blood or bodily fluids contaminate property while at work, employees shall place the items in a red "BIO HAZARD" plastic bag. The bag shall be sealed and have an appropriate label. The employee must verbally notify his/her immediate supervisor or his designee that potentially infectious disease-contaminated items are in his/her possession.

Resuscitator masks and evidence collection equipment contaminated with blood or other bodily fluids shall be disinfected after each use according to the appropriate guidelines.

B. Line of Duty Exposure
When an employee has cause to believe they have been exposed to high risk during the line of duty, appropriate documentation will be prepared. High risk exposure includes handling bloody or wet items where scratches, cuts or open sores are noticed; direct contact with bodily fluids on an area where there is an open sore or cut; direct mouth-to-mouth resuscitation (CPR); the receiving of a cut or puncture wound.

If an employee is exposed, a supervisor will be contacted and an accident report detailing the exposure will be completed. All necessary forms will be forwarded to Human Resources and Plant Operations.

Exposed employees will be evaluated clinically and serologically for evidence of infection after the exposure. This will be done through Concentra Medical Clinic. A copy of the medical report shall be placed in the employee's confidential medical file. At the recommendation of the treating physician, follow up examinations and/or testing will be provided through Concentra Medical Clinic.

IX. General Decontamination and Clean Up

If exposed, wash hands thoroughly and immediately with hot water and a virocidal-germicidal soap. Uniforms or other clothing soiled with blood or bodily fluids should be laundered in a household bleach solution. Fabrics requiring dry-cleaning should be diluted in cold water and placed in a red "BIO HAZARD" plastic bag, tagged, and sent to a licensed medical waste disposal facility.

Area supervisors are responsible for replacing used equipment from departmental supplies and ensuring that adequate supplies are available. Protective gloves, first aid supplies and disinfecting materials will be readily available at all times. Supplies shall include infectious control kits, red "BIO HAZARD" sealing plastic bags with labels, spray bottles containing liquid and aerosol germicidal cleaner, and disposable handwipes (70% isopropyl alcohol). The Hazardous Material/Environmental Technician or his designee shall be responsible for the inventory and dissemination of supplies for infectious disease control.

X. Vaccination

Macomb Community College will provide Hepatitis B vaccinations to all personnel who may come into contact with blood or other potentially infectious materials in the performance of job duties. The Hepatitis B vaccination consists of a pre-test, three inoculations, and a post-test. If an employee declines the vaccination, they must sign the vaccine declination. If the employee later decides to have the vaccines, the vaccine will be provided at College expense. The vaccination will be administered by a licensed medical professional.

Post exposure evaluation and follow-up will be available to all employees who have an exposure incident. These services will be provided free of charge, at a reasonable time and place, performed by or under the supervision of a licensed physician or other licensed health care professional, and provided in accordance with the recommendations of the US Public Health Service.

The post exposure evaluation and follow-up shall be made available immediately and shall include:

  1. The documentation and route(s) of exposure and the circumstances of the exposure.
  2. The identification and documentation of the source individual, unless this is infeasible or prohibited by law.
  3. A test of the source individual's blood after consent and as soon as possible. If consent isn't possible, the College will document that fact. If consent isn't required, the blood will be tested and the results documented. If the source individual is known to be HIV+ or HBV+, it is not necessary to test his blood.
  4. Notification to the employee of the results of the testing. The employee will also be notified of the applicable laws and regulations regarding disclosure of the identity and infectious status of the person.
  5. A blood test of the employee after consent is obtained.
  6. Post exposure prophylaxis when medically indicated.
  7. Counseling.
  8. Evaluation of reported illnesses.

XI. Record Keeping

Accurate medical records shall be kept in a confidential medical file for each employee with an occupational exposure. The record will contain all the necessary information required by the Standard. Medical records will not be released without the written permission of the employee or as required by law. Medical records will be maintained for the duration of employment plus 30 years as required by the Standard. The medical records will contain the appropriate information regarding Hepatitis B vaccines or the refusal form.

A sharps injury log containing the type and brand of device involved in the incident, the department/work area where the exposure occurred, and an explanation of how the incident occurred shall be maintained. The log shall be kept for the length of time required by the Standard.

Training records will be maintained as required by the Standard.

NOTE: The "Good Samaritan Act" would not be covered by this Bloodborne Pathogens Standard.

Approved by the Board of Trustees
Macomb Community College
December 15, 1992
Revised May 15, 2001
(Reviewed by Office of General Counsel, December 2011)
Updated pursuant to Board authorization, January 2023