4600P Bloodborne Pathogens; Exposure Control (Procedures)

Original Date: 9/14/1994 * Last Revision Effective: 3/20/2024
Policy Contact: Vice President, Human Resources


The following procedures are established to meet the requirements for implementing policy #4600 – Bloodborne Pathogens; Exposure Control.


The Bellevue College exposure control program consists of the following parts: exposure determination, methods of compliance, Hepatitis B vaccination program, exposure incident evaluation and follow-up, training, and policy enforcement/responsibilities.

Exposure Determination

The safety committee maintains a list of job classifications in which employees have occupational exposure due to their job requirements. Rationale for the classifications has been identified. Other positions may be reviewed on a case-by-case basis using the exposure determination by task assessment form.

Methods of Compliance

Universal precautions

The Centers for Disease Control have recognized the following body fluids as being directly linked to the transmission of HIV and/or Hepatitis B: blood, semen, blood products, vaginal secretions, cerebrospinal fluid, synovial fluid, and amniotic fluid. Body secretions like nasal drainage, sputum, vomitus, urine, and feces are not directly linked to the transmission of HIV and/or Hepatitis B if it can be determined that blood is not present in these body secretions. When blood is present or if it is impossible to determine whether blood is present, the employee will follow universal precautions, i.e., assume that the blood/body secretion is potentially infected. A prescribed level of personal protective equipment as the minimum precaution shall be observed by the employee to prevent exposure to blood. Health science/health care program faculty who are assigned to clinical agencies shall adhere to the universal precautions or body substance isolation procedures required by those agencies.

Engineering controls and work practice controls

Controls used to eliminate or isolate exposure potential are reviewed annually and as needed by the safety committee.

  • Needles/ syringes/sharps disposal containers. Labeled puncture-resistant containers are available in the nursing laboratories.
    • Work practice controls: Disposable contaminated needles and syringes shall not be bent, recapped, broken, or removed and will be disposed of in approved sharps disposal containers. Sharps disposal containers will be transported to the science department for discarding by an appropriate agency.
  • Clean-up kits. Clean-up kits consisting of disposable rubber gloves, pick-up spatula, germicidal detergent and wiping cloth, contaminated materials/plastic bag with tie, and antiseptic hand rinse will be available with first aid kits. Additionally, departmental managers will issue clean-up kits to appropriate individual employees (e.g., custodians, public safety officers, etc).
    • Work practice controls:
      • Employees who encounter products containing blood or other potentially infectious material (e.g., used condoms, feminine hygiene products, etc.) will not directly touch the used products. The clean-up kit will be used whenever possible to prevent contact with potentially infected body fluids.
      • Employees who participate in first aid will use the clean-up kit to prevent exposure to potentially infectious materials.
  • Mechanical assistance devices. Pick-up tools like tongs or broom/dustpan combination or broom/shovel combination will be a part of the custodial and grounds maintenance employees’ equipment to be used in the clean-up of broken glass and any sharp objects.
    • Work practice controls: In all cases of unprotected needles or syringes and any sharps or broken glass which are found on the floor or the grounds, pick-up will be by mechanical assistance to minimize exposure. The needle, syringe, sharp, or broken glass will then be placed in a container which has an impervious bottom and sides.
  • Handwashing Facilities. Handwashing facilities will be readily available for all employees, in all restrooms, in all laboratory classrooms and in the early learning center.
    • Work practice controls:
      • Employees will use the prescribed personal protective equipment (PPE) each time they perform a task or procedure involving occupational exposure.
      • Employees will wash with soap and water immediately or as soon as feasible after removal of PPEs.
      • Employees working in areas where hand washing facilities are not readily available will use antiseptic hand rinse (provided in the clean-up kit).
      • Following any contact with potentially infectious material, the exposed skin will be immediately washed with soap and water or the mucous membrane will be flushed with water.
  • First aid and safety devices. A first aid kit, one disposable mouthpiece, and a clean-up kit can be ordered by each department and education office. Public safety officers will have disposable mouthpieces, disposable rubber gloves, goggles, first aid kits, and clean-up kits as part of their PPEs. As safety devices are marketed they will be evaluated and their effectiveness determined in incident prevention.
    • Work practice controls:
      • All personnel will comply with the directive emergency information which is posted in each office, classroom, and work area. It is the responsibility of the employee to follow the emergency information for emergency situations. Employees are not required to and in most cases are not expected to perform CPR. In providing first aid, the employee is expected to recognize their own capabilities and limitations and to follow guidelines and use equipment designed to protect themselves from any contact with potentially infectious body fluids.
      • Employees who provide first aid will use the appropriate PPEs to prevent contact with body fluids.
        • In the case of a minor injury, the employee will use the first aid kit and provide the injured person with a sterile dressing/bandage or clean paper towel to stop the bleeding and an antiseptic to clean the site followed by the application of a sterile dressing or bandage. The injured individual is then to place the contaminated articles into a leak proof plastic bag. Any soiled surfaces are to be disinfected by using the gloves and solution provided in the clean-up kit. All contaminated articles are to be placed into a leak proof bag which is secured by knotting or tie closing the opening, then placed into a regular waste container.
        • In case of injury which involves blood or other body fluids and which cannot be managed by the injured individual, the employee must first determine their ability to provide first aid. If the employee has determined that they are able to provide first aid, a clean-up kit will be used in conjunction with the first aid kit. The employee will put on the disposable rubber gloves from the clean-up kit before providing any first aid. Following first aid, a clean-up kit will be used to clean and disinfect any soiled surface. The employee will cleanse their hands using the antiseptic hand rinse provided in the clean-up kit. The used clean-up kit, used first aid materials, and other used disposable materials will be placed in a leak proof bag and secured with a tie before disposal. The employee will wash their hands with running water and soap as soon as possible following this procedure.

Other work practice controls

  • Contaminated sharp tools, immediately or as soon as possible after use, will be cleaned with an appropriate disinfectant (such as 10,000 ppm of stabilized chlorine).
  • Contaminated surfaces will be cleaned immediately or as soon as possible after an incident with an appropriate disinfectant (such as 10,000 ppm of stabilized chlorine).

Personal protective equipment (PPE)

PPE is considered appropriate if it does not permit blood/body fluids to pass through to the employee’s clothes, skin, or mucous membranes.

  • PPE will be provided at no cost to an employee performing a task or procedure involving occupational exposure. Clinical faculty in health care programs will use the personal protective equipment provided by the clinical agency.
  • The appropriate PPE will be readily accessible in the work area and/or will be issued to the employee by the department manager.
  • PPE will be removed prior to leaving the work area.
  • All PPE will be disposed of by Bellevue College or an agency employed by the college.
  • PPE that is not disposable (e.g., work gloves that can be rinsed with a disinfectant) will be used as long as it operates as a barrier, after which it will immediately be replaced at no cost to the employee.
  • In the event that a piece of an employee’s personal clothing is exposed to another person’s blood or potentially infectious material, the employee must notify his/her immediate supervisor who will arrange for disposition of the garment.
  • Custodial services. Custodial employees are required to ensure that the work area is maintained in a clean and sanitary condition. Departmental guidelines for cleaning work areas and equipment are to be followed.

Hepatitis B vaccination program

  • All employees who have been identified as having occupational exposure will be offered the hepatitis B vaccination series during the training program and within ten days of employment or assignment.
  • All employees who have been identified as having occupational exposure are required to complete the series of vaccinations or to sign a waiver declining vaccination. An employee who declines vaccination may at a later date request the vaccine. The vaccine series must be provided by a qualified health care provider. A record of the vaccination series must be submitted to the supervisor for reimbursement of the cost. The supervisor will forward a copy of the vaccination record to human resources for record-keeping.
  • The following declination statement is mandated by WAC 296-823-13005: “I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that 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 hepatitis B vaccine, I can receive the vaccination series at no charge to me.”

Exposure incident evaluation and follow-up

  • Whenever there is any eye, mouth, non-intact skin, or parenteral contact with blood or other potentially infectious materials, an exposure incident evaluation must take place. The exposure incident report form is to be completed by a qualified health care provider. The form must be completed within 24 hours of the incident. The evaluation will be facilitated by the college at no cost to the employee.
  • The safety committee will annually review reports of incidents including action taken to reduce future incidents.

Training program

  • All employees with occupational exposure will receive instruction in the requirements of the training program upon employment or assignment and annual updates on any new information. Other employees will participate in a portion or all of the training program as deemed appropriate by the department manager/administrator. This instruction will be provided by a qualified individual. Training will utilize group presentations, videotapes, and self-study modules to meet employee needs.
  • Training records will be maintained by each department and human resources for a period of three years. Training records shall contain the dates of the training, names and qualifications of instructors, and names and job titles of employees attending the training sessions.
  • A copy of the exposure control program will be accessible to all employees.

Policy enforcement/responsibilities

All employees

  • are responsible for working in a safe manner. All employees are required to read all safety practices and rules and to follow them at all times.
  • are responsible for reporting all unsafe situations to their immediate supervisors and to campus operations.
  • who are classified as having occupational exposure are required to complete the training program including annual updates as indicated. Waivers will be signed by employees with occupational exposure who choose not to receive the hepatitis B vaccine.
  • are to report any exposure incidents to their supervisors within their working shift or day.

Department directors/managers/supervisors

  • will supervise their employees in following the requirements of this exposure control program.
  • will assure that all employees who are identified as having occupational exposure are instructed in the requirements of the exposure control program upon employment and receive annual updates thereafter.
  • will provide education on the department-specific functions and procedures related to accident prevention and the requirements to be followed in an exposure incident.
  • will conduct investigations of policy exceptions by employees or exposure incidents and, as needed, take corrective action to eliminate, isolate, minimize, or reduce another like incident.
  • will monitor the program within the department and report problems to the safety committee.

Safety committee

  • will monitor the institutional program for problem areas and make recommendations for corrective actions to the vice president of administrative services.
  • will review the program at least annually and revise it as necessary.

Revision History

Original 5/4/1994
Revisions 3/22/2005; 5/21/2009; 9/11/2012; 4/21/2015; 3/20/2024

Approved By

President’s Cabinet

Last Updated March 20, 2024