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Univeristy of Maine at Augusta

Bloodborne Pathogen Exposure Control Plan

 The purpose of the University of Maine at Augusta’s Bloodborne Pathogen Exposure Control Plan is to eliminate or minimize employee occupational exposure to blood or other potentially infectious materials (OPIM).  Job classifications that might reasonably be expected to be at risk for exposure are:


High and medium risk employees receive specialized training specific to their job and the tasks involved.  The training is based upon the area specific information provided by the area supervisor and lists the tasks and procedures where exposure to blood or other potentially infectious materials may be likely to occur.

High risk employees are:

  1. Faculty, professional clinical teachers and the clinic coordinator employed in the Dental Health Clinic on the Bangor campus
  2. Faculty and staff employed in the Veterinarian Technology Clinic on the Bangor campus.
  3. Faculty in the Nursing Education Program on the Augusta campus.
  4. Faculty in the Med Lab Tech Program at the Augusta campus.


Medium risk employees are:

  1. Members of the Building & Grounds Maintenance staff
  2. Members of the Custodial Staff
  3. Coaches employed by the Student Activities Office
  4. Security Guards


The following supervisors are responsible for the implementation of this plan:

  • Dean of the College of Professional Studies (Brenda McAleer) for the members  of the staff in the Dental Health Clinic, the Veterinarian Technology Clinic, and the Nursing Education Program as well as the Program Coordinators.
  • Director of Facilities at Augusta (Peter St. Michel) and Maintenance Supervisor at Bangor (Patrick Decker) for the members of the custodial staff, the security staff and the building and grounds maintenance staff as well as the Custodial Supervisors at Augusta (Charles Hersom) and UMA-Bangor (Joseph Wojdakowski), the Building Services Supervisor at Augusta (Mark Theriault) and the Maintenance Supervisor at UMA-Bangor (Patrick Decker).
  • Dean of Students (Kathleen Dexter) and Director of Student Activities and Athletics (Warren Newton) for the coaches as well as the Staff Associates for the Fitness Center and Student Activities at Augusta (Jennifer Laney) and at Bangor (Kristy Albee).



It is the policy of the University of Maine at Augusta to utilize Universal Precautions.  This is a system of infection control that assumes that all human blood and certain body fluids are known to be infectious for HIV, HBV and other bloodborne pathogens.  Universal Precautions shall be used at all times and for all individuals.

The body fluids directly linked to the transmission of bloodborne pathogens are blood, blood products, semen, vaginal secretions, synovial (joint space) fluid, peritoneal (body cavity) fluid, pleural (lung space) fluid, amniotic (birth water) fluid, saliva in dental procedures, and any body fluid that cannot be identified.

Gloves will be worn when direct contact can reasonably be expected.  Gloves will be put on prior to beginning the task and removed when the task is completed.  Hands must be washed with soap and water, or if no visible blood in the fluid, may use an alcohol based hand rub, both immediately after removal of gloves.

Hands and any other area must be washed with soap and water immediately when an exposure incident (such as a splash) has occurred.  Flush eyes with water.  Employees must familiarize themselves with the nearest hand-washing facility and the location of emergency eyewash stations and showers.  When an antiseptic hand cleaner or towelettes is used, hands must be washed with soap and water as soon as possible.

Physical Plant employees who encounter improperly disposed needle(s) will notify the Office of Administrative Services to report the location of the needle(s).  Needles will be disposed in labeled sharps containers.  If a container is not available at the location, a puncture-resistant container will be used.  Needle(s) will be moved using pliers or a broom and dust pan and placed in the puncture-resistant container and sealed immediately.

No eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses is allowed in an area where there is a reasonable likelihood of exposure.

Decontamination of an area will be accomplished by using:

10% (minimum) solution of chlorine bleach

All contaminated surfaces, tools, and objects will be decontaminated immediately using the bleach solution.  This solution must be left in contact with the contaminated surface or object for at least 10 minutes before cleaning continues.

To avoid possible injury, broken glassware will not be picked up directly with the hands.  Sweep or brush the broken pieces into a dustpan.  Pieces of broken glassware should be disposed in a container that the glass cannot penetrate.  This container should be sealed to ensure no one would unknowingly be injured.


Sharps must not be bent, sheared, broken or recapped by hand.  Needles and other sharps must be discarded in rigid, leak-proof, puncture-resistant containers for disposal.  Containers should be located as close as practical to the area of use and identified as biohazardous. 

An annual review of innovations in medical procedures and technology (i.e., newly available medical devices designed to reduce needlesticks) designed to reduce the risk of exposure will be undertaken.  This review will include documentation of the consideration and use of appropriate, commercially-available, and effective safer devices.  The documentation will describe the devices considered for use, the methods used to evaluate those devices, and the justification of the eventual selection of a safer device.

Input regarding the identification, evaluation, and selection of effective safer medical devices will be solicited from non-managerial employees who will be using these devices.  The participation of non-managerial employees will be documented by listing the employees involved and describing the process used each year to evaluate new devices for possible use.


Personal protective equipment will be provided by the appropriate supervisor based on the anticipated exposure to blood or other potentially infectious materials.  The personal protective equipment will be considered appropriate if it does not permit blood or other potentially infectious materials to pass through or reach the employee’s clothing, skin, eyes, mouth, or mucous membranes under normal conditions of use.



All employees identified in this plan shall participate in a training program provided by the University.  Training will be provided on an annual basis and will include:

  1. An accessible copy of the regulatory text of the Bloodborne Pathogens Standard and an explanation of its contents.
  2. A general explanation of the epidemiology and symptoms of bloodborne diseases.
  3. An explanation of the modes of transmission of bloodborne pathogens.
  4. An explanation of the Exposure Control Plan and the means by which the employee can obtain a copy of the written plan.
  5. An explanation of the appropriate methods of recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
  6. An explanation of the use and limitations of methods that will prevent or reduce exposure, including appropriate engineering controls, work practices and personal protective equipment.
  7. Information on the types, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment.
  8. An explanation of the basis for selection of personal protective equipment.
  9. Information of the Hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge.
  10. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
  11. An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
  12. Information on the post-exposure evaluation and follow-up that will be provided for the employee following an exposure incident.
  13. An explanation of the biohazard signs and labels and/or color-coding required by the facility and by the law.
  14. An opportunity for interactive questions and answers with the person conducting the training.

Hepatitis B Vaccine:  The Hepatitis B vaccination shall be made available after the employee has received the training in occupational exposure.  It shall be made available to all employees who have the potential to be exposed to bloodborne pathogens unless the employee has previously received the complete Hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.

If the employee initially declines Hepatitis B vaccination but at a later date decides to accept the vaccination, the vaccination shall be made available at that time.

All employees who decline the Hepatitis B vaccination offered shall sign the OSHA required waiver indicating their refusal.  The waiver shall be done annually.


If an employee has an exposure incident, the employee shall file an incident report with the supervisor as soon as possible.  The exposure will be investigated and documented. 

The incident report will document the route (s) of exposure and include a description of the circumstances under which the exposure occurred.  If possible, the source individual will be identified and permission will be requested to collect and test the source individual’s blood.  If the source individual is unknown or refuses permission for testing, it will be assumed that the source individual is infected. 

Following the report of an exposure incident, the exposed employee will be referred to the University’s preferred medical provider for a confidential medical evaluation and follow-up.  Counseling will be provided.  Post-exposure treatment for the employee, if medically indicated, will be provided.

The University’s preferred medical provider will be provided a copy of this plan, a copy of the incident report, vaccination status of the employee, and the results of any testing that was done.

The University will provide the employee with a copy of the preferred medical provider’s written opinion regarding the exposure incident.  This written opinion will include (1) whether the employee needed and has received the Hepatitis B vaccination; (2) that the employee was informed of the results of the evaluation; (3) that the employee was informed about any medical conditions resulting from exposure to blood or other infectious materials that require further evaluation or treatment.  All other medical information will remain confidential and will not be in a written report.


An Injury Log of those employees who have experienced a needlestick injury is required under the OSHA Bloodborne Pathogens Standard.  This log will be maintained by the Office of Administrative Services in a manner that protects the privacy of the employees and will contain the following information:

  1. The type and brand of device involved in the incident
  2. The location of the incident
  3. A description of the incident

Medical records are kept separate from employee personnel files.  Each medical record for employees covered by this Plan will include:  Hepatitis B vaccination status, dates of vaccinations (if applicable), and any pertinent information resulting from any incident.  Confidential medical records will be maintained by the Office of Administrative Services for thirty (30) years after an employee’s termination date (Administrative Practice Letter 46).

Training records will be maintained by the office responsible for the training with copies forwarded to the Office of Administrative Services.  These records will be maintained for 30 years or the length of employment (whichever is longer).

A copy of this Plan will be on file in the Office of Administrative Services and in the following offices:

  • Dean of the College of Professional Studies
  • Dental Health Clinic
  • Veterinarian Technology Clinic
  • Nursing Education Program
  • Director of Facilities at Augusta
  • Director of Administrative Services at Bangor


This plan will be reviewed and updated as necessary on an annual basis by the Office of Administrative Services with assistance from the offices covered by the Plan.


  • Hepatitis B Vaccine Declination Form
  • Bloodborne Pathogen Training Record
  • Supervisor’s Instructions for Bloodborne Pathogens Incident
  • --Bloodborne Pathogen Exposure Checklist
  • --Exposure Incident Report
  • Outline for Annual Review (Sharps)




10/14/2014 rm