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Name: Bloodborne Pathogen Exposure Control Plan - ECP
Responsible Office: Environmental Health & Safety

Applies to: (examples; Faculty,Staff, Students, etc)

Faculty , Staff , Students

Policy Overview:

Issued: 05-01-2015
Next Review Date: 09-15-2021
Frequency of Reviews: Annually

The St. Louis College of Pharmacy is committed to providing a safe and healthful educational and employment environment for its entire population. In pursuit of this endeavor, the STLCOP Bloodborne Pathogens Exposure Control Plan has been enacted to eliminate or minimize potential student and employee exposures to bloodborne pathogens and to comply with OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens.”

Table of Contents:

This Exposure Control Plan (ECP) includes the following sections:


Policy Details

I. Introduction

II. Program Administration

III. Employee Exposure Determination


IV. Methods of Implementation and Control

A. Exposure Control Plan
B. Universal Precautions
C. Engineering Controls
D. Work Practices
E. Personal Protective Equipment
F. Housekeeping
G. Laundry
H. Spill Clean-up Procedures
I. Labels and Signage

V. Medical Surveillance

A. Hepatitis B Vaccination
B. Post-Exposure Evaluation and Follow-Up

VI. Evaluation of Circumstances Surrounding an Exposure Incident

VII. Employee Training

VIII. Recordkeeping

A. Training Records
B. Medical Records
C. OSHA Records
D. OSHA Sharps Injury Log



Policy Contacts

Appendix A: Hepatitis B Vaccine Declination Form

Appendix B: Exposure Incident Flow Chart


Administrative Controls: Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Blood: Human blood, human blood components, and products made from human blood.

Bloodborne Pathogens: Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV), and can be found in all body fluids, unfixed tissue, cell lines, and in situations where it is difficult or impossible to differentiate between body fluids and other materials.

Clinical Laboratory: A location or facility where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

Contamination: The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

Contaminated Laundry: Laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.

Contaminated Sharps: Any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes and exposed ends of dental wires.

Decontamination: The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.

Engineering Controls: Controls (e.g., sharps disposal containers, self-sheathing needles) that isolate or remove the bloodborne pathogen exposure hazard.

Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious materials.

Exposure Potential: Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an individual’s duties.

HCV: Hepatitis C virus

HBV: Hepatitis B virus

HIV: Human Immunodeficiency Virus

Other Potentially Infectious Materials (OPIM): (1) The following human body fluids:  semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); (3) Human immunodeficiency virus (HIV)-containing or Hepatitis B virus (HBV)-containing cell or tissue cultures, organ cultures, and HIV- or HCV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HCV.

Parenteral: Piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.

Personal Protective Equipment (PPE): Specialized clothing or equipment worn by an individual for protection against a hazard. General clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

Regulated Waste: Liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

Source Individual: Any individual, living or dead, whose blood or other potentially infectious materials may be a source of exposure to an individual. Examples include, but are not limited to, hospital and clinic patients; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.

Universal Precautions: An approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, HCV and other bloodborne pathogens.


I. Introduction

The St. Louis College of Pharmacy is committed to providing a safe and healthful educational and employment environment for its entire population. In pursuit of this endeavor, the STLCOP Bloodborne Pathogens Exposure Control Plan has been enacted to comply with the Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens Standard (29 CFR 1910.1030), and to eliminate or minimize potential employee and student exposures to blood, certain other body fluids, or other potentially infectious materials (OPIM).

II. Program Administration

A. The Office of Emergency Management and Environmental Health & Safety is responsible for implementation of the ECP. They will maintain, review and update this plan annually and whenever necessary to include new or modified procedures, with support from other STLCOP stakeholders.

B. Employees and students who are determined to have potential exposure to blood or OPIM must comply with the procedures and practices outlined in the ECP.

C. The personnel representing various the departments, labs or offices listed below will provide and maintain all necessary PPE, engineering controls (e.g. sharps containers, safety lancets), labels and biohazard boxes and red bags as required by 29 CFR 1910.1030. They will also ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes.



Contact Person

Phone Number

Faculty Research Lab


Tony Wilmes

(314) 446-8190

Basic Sciences

Biology & Anatomy

Sarah Schlereth

(314) 446-8480


Priyaah Pratt

(314) 446-8339


Kamelia Markova

(314) 446-8477

Physiology & Physics

Tony Wilmes

(314) 446-8190



Rhonda Bilger

(314) 446-8472


Gloria Grice

(314) 446-8550

Pharmacy Practice

Tricia Berry

(314) 446-8514

College Operations


Terry Richars/Marty Massey

(314) 446-8379

Facilities Management

Terry Richars/Marty Massey

(314) 446-8379


Carlin Harp

(314) 446-8133

Clinical Lab Space

ARB 6th Floor

Carlin Harp

(314) 446-8133

D. The Department of Human Resources will be responsible for ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained.

E. The Admissions Office is responsible for retaining the Student Health Record (SHR) – comprised of immunization/vaccination history, medical evaluations, exposure incident report copies and other appropriate information – for all freshman, sophomore and junior students.

F. The Office of Experiential Education is responsible for retaining, updating and ensuring authenticity of the SHR upon a student’s entry into the professional pharmacy program for the remainder of their academic career. They are also responsible for ensuring students have completed all necessary initial and refresher training.

G. The Office of Emergency Management and Environmental Health & Safety is responsible for ensuring appropriate individuals complete initial and annual refresher bloodborne pathogen training, maintaining documentation of training and providing the ECP to employees, students and any requesting regulatory agency representatives.

III. Exposure Potential Determination

A. The following is a matrix of all roles at the College in which all personnel have occupational exposure:


Role/Job Classification

Athletics, Fitness and Recreation

Head Coach

Assistant Coach

Athletic Training/Injury Evaluator (Contract Employee)

Facilities Management



Security Services


Security Officer (Contract Employee)

B. The following is a list of roles in which some employees and/or students at the College have exposure potential. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which exposure may occur for these individuals:


Job Classification/Position


Academic Departments

-        Basic Sciences

-        Pharmacy Practice

-        Pharmaceutical and Administrative Sciences

Adjunct Professor

Assistant Professor

Associate Professor


Lab Materials Manager

Pharmacy Resident


Research Assistant


Teaching Assistant


Work with blood or OPIM

Handling sharps

Spill cleanup

Athletics, Fitness and Recreation

Student Athlete

Student Worker

Collect/handle uniforms, towels

College Services

Assistant Vice President

Emergency response

Spill cleanup

Dining Services

Service Worker (Contract)

Knife cuts

Emergency Management/EH&S

Associate Director

Emergency response

Spill cleanup

Facilities Management

Maintenance Staff



Equipment cleaning/maintenance

Emergency response/repairs


IV. Methods of Implementation and Control

A. Exposure Control Plan

Employees and students covered by the Bloodborne Pathogens standard receive an explanation of this ECP during their initial training session or orientation. It will also be reviewed in their annual refresher training. All STLCOP community members have an opportunity to view this plan at any time by logging into MySTLCOP, contacting their supervisor or requesting a copy from the Office of Emergency Management and Environmental Health & Safety. If requested, the employee or student will receive a copy of the ECP free of charge within 15 days of their request.

The Associate Director of Emergency Management and Environmental Health & Safety is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures that affect occupational exposure or the implementation of the ECP.

B. Universal Precautions

All employees and students will use Universal Precautions, a method of infection control in which all human blood, tissue, and OPIM are treated as if known to be infectious for HIV, HBV, HCV, or other bloodborne pathogens.

Universal precautions are intended to prevent occupational exposures. The routes of transmission for occupational exposure are 1) puncture of the skin with a contaminated sharp object, 2) contact with broken skin, and 3) splash to mucous membranes of the eye, nose, or mouth.

C. Engineering Controls

Engineering controls are devices that eliminate or reduce the risk of potential exposure by removing or isolating the individual from the hazard.

i. Containers, specifically engineered for sharps, must be used for disposal of all needles, syringes and other sharps. Sharps containers must be disposable, non-breakable, puncture resistant, leak-proof, sealable and labeled with the universal biohazard symbol. Sharps containers are frequently inspected and monitored by the appropriate Lab Materials Manager and during routine lab inspections, and must be collected and replaced whenever they are ¾ full.

ii. Sharps with engineered injury protection and needleless systems are recommended. College lab personnel (supervisors, faculty and laboratory staff) continually evaluate devices for effectiveness in reducing the risk of exposure incidents.

iii. Mechanical pipetting devices must be used. Mouth pipetting is prohibited.
It is the responsibility of the Lab Materials Manager to evaluate engineering controls and maintain them on a regular schedule. Contaminated equipment must be removed from circulation and decontaminated at the end of the work day or after a spill.

D. Administrative Controls

Administrative controls are modifications of task procedures and processes to reduce the likelihood of exposure to blood or other potentially infectious material.

i. Hand washing facilities must be readily accessible to all students and employees who may incur exposure to blood or OPIM. Hand washing sinks are located in all laboratories, workshops and storage areas. All students and employees will wash hands after removing gloves and other PPE, before leaving the lab and immediately after contact with blood or OPIM.

ii. Contaminated needles will not be bent, recapped or removed from syringes unless no alternative is feasible for the procedure. Such bending, recapping or removal must be accomplished through the use of a mechanical device or the one-handed technique.

iii. Work area restrictions – in work areas where there is a reasonable likelihood of exposure to blood or OPIM, employees and students shall not eat, drink, apply cosmetics or lip balm, smoke or handle contact lenses. Food and beverages shall not be consumed or stored in refrigerators, freezers, laboratories or clinics where blood or OPIM may be present.

iv. All procedures will be conducted in a manner that minimizes splashing, spraying, splattering and generation of droplets of blood or OPIM. The Lab Materials Manager is responsible for identifying methods that will be used to minimize these hazards in their laboratory.

v. Specimens of blood and OPIM will be placed in containers that will prevent leakage during collection, handling, processing, storage and transport. All containers and equipment in which blood or OPIM are stored will be appropriately labeled.

vi. All shippers of infectious material and any materials on dry ice must be trained on DOT/IATA shipping regulations. IATA training is required every two years and DOT training every three years. For information on how to receive training, contact STLCOP Emergency Management and Environmental Health & Safety at (314) 446-8206.

vii. Equipment which has been contaminated with blood or OPIM will be decontaminated as necessary prior to servicing, disposal or relocation. If decontamination is not feasible, the contaminated portion of the equipment will be labeled and this information will be conveyed to all affected parties prior to handling, servicing or shipping. All biohazard labels will be removed after decontamination and prior to disposal.

The College identifies the need for changes in engineering and administrative controls through at least annual review of incident reports and/or OSHA-mandated sharps injury logs, and communication with Lab Materials Managers and other lab employees to inquire about any near-misses. Any findings may then be discussed by the STLCOP EH&S Team, or may be addressed directly by the Office of Emergency Management and Environmental Health & Safety.

New products are evaluated regularly by STLCOP lab workers and management officials. Lab Materials Managers and/or Principal Investigators (PIs) review, at least annually, appropriate professional journals, consult with others in their field of expertise and with suppliers to remain current on standard/best practices, find out about and assess new products, and make recommendations as needed to the STLCOP EH&S Team. If it is determined that changes are needed, the Associate Director of Emergency Management and EH&S responsible for ensuring that the recommended changes are implemented.

E. Personal Protective Equipment

Personal protective equipment (PPE) is specialized clothing or equipment worn by individuals for protection against a particular hazard. When the potential for exposure remains after the institution of engineering and administrative controls, STLCOP employees and students will use PPE. The Lab Materials Manager/Department Chair (specified in Section II.C of this plan) is responsible for ensuring their respective employees and students are trained and understand the appropriate use of PPE needed to perform specific tasks or procedures.

Please refer to the STLCOP Personal Protective Equipment (PPE) Policy for additional information and clarification. The following protective clothing and equipment will be made available for use depending upon the activity performed:

i. Gloves - Gloves shall be worn when it is reasonably anticipated that employees and students may have hand contact with blood, OPIM, non-intact skin and mucous membranes, and when handling or touching contaminated items or surfaces. There are several types of gloves available, and selection should be based upon the job being performed.

Latex or nitrile gloves are used for operations involving delicate manipulations. These gloves are designed to fit tightly against the skin. The proper size should be selected to fit the individual’s hands. Latex and nitrile gloves are available either powdered or powder-free. If an individual has a skin reaction from the gloves, hypo-allergenic and/or powder-free types must be provided. All such gloves are disposable and are not to be washed or decontaminated for reuse and are to be replaced as soon as feasibly possible after contamination, or if they are torn or punctured.

Rubber, neoprene or other thicker reusable gloves are more durable and are generally used for more strenuous activities, such as cleaning spills. They may be decontaminated for reuse provided their integrity is not compromised. Reusable gloves should be periodically inspected for signs of cracking, peeling, tearing, puncturing, deterioration or discoloration; if any are found, the gloves must be discarded.

Hand jewelry should be kept to a minimum as to not puncture or tear disposable nitrile or latex gloves.

ii. Eyewear - Goggles with solid side shields or chin-length face shields must be worn when there is a risk of splashing human blood or OPIM. This protective equipment reduces the potential for contact with the mucous membranes of the eyes.

iii. Face Protection - The use of protective masks is intended to reduce the risk of splashing human blood onto the mucous membranes of the nose and mouth. If masks are disposable, they must be removed immediately following use and not be reused. Reusable masks and face shields must be properly handled, cleaned and decontaminated prior to reuse.

If work requires the use of a respirator, that individual must participate in the College’s respiratory protection program.

Employees and students must have prior medical clearance to wear a respirator and must consult with EH&S on the selection and use of respiratory protection equipment. Annual fit testing is also required.

iv. Protective Clothing - Appropriate protective clothing such as lab coats, gowns, aprons, or similar outer garments shall be worn when there is a risk of human blood or OPIM spattering skin or clothing. Protective clothing should be resistant to fluids, and may be disposable or reusable. Reusable clothing must be properly laundered prior to reuse. Additionally, close-toed footwear is required for all laboratory work and procedures.

All employees and students using PPE must observe the following precautions:

• Wash hands immediately or as soon as feasible after removal of gloves or other PPE
• Remove PPE after it becomes contaminated, and before leaving the work area
• Disposable PPE may be discarded in any approved biohazard collection container
• Reusable PPE such as goggles shall be decontaminated with appropriate disinfectant, or if apparel such as a lab coat, placed into containment bag until properly laundered.
• Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with the outer surface

All PPE will be cleaned, laundered or disposed of by the College at no cost to students or employees. Soiled PPE must not be taken home to launder. The College will make all PPE acquisitions, repairs and replacements at no cost to employees. Students are responsible for the costs associated with obtaining and replacing all necessary PPE in accordance with the STLCOP Personal Protective Equipment (PPE) Policy and requirements set forth by the department or course instructor.

F. Housekeeping

Normal Housekeeping

The routine cleanup and disinfection of bathrooms and dormitory bedroom areas are not considered activities that fall under the requirements of the Bloodborne Pathogens Standard. It is recognized, however, that infectious agents responsible for other commonly-occurring diseases may be present. Application of disinfectant to bathroom surfaces is commonly used to reduce occurrences of such diseases. Disinfectants used for this purpose must be used according to the manufacturer's directions. The Safety Data Sheet (SDS) may also reference use of PPE.

Employees who are responsible for housekeeping activities in bathrooms need to take precautionary measures to prevent contact with human blood or OPIM. Follow the Work Practice and Engineering controls in the sections IV. D and C for the cleanup and decontamination of potentially infectious material such as blood spills, contaminated razors, broken glass, used condoms, etc.
Disposable razors are routinely discarded in dormitory bathroom facilities. Staff who are responsible for housekeeping in these areas may carefully handle and discard these razors into the general trash containers unless they are visibly contaminated with human blood or OPIM, or damaged in such a way that the razor blade is exposed. In these situations, workers must wear appropriate gloves and carefully place the razors into an appropriate sharps container. If a razor cannot be easily handled due to breakage, or if a bare razor blade must be discarded, the employee shall pick up the razor with tongs or tweezers.

If feminine hygiene products have been placed into the bathroom's common waste receptacle, and the receptacle is lined with a plastic bag, the bag may be removed and disposed as normal trash. Employees should wear gloves when removing and handling the trash bag.

Laboratory Housekeeping

All lab equipment and work surfaces must be cleaned and decontaminated with an appropriate disinfectant (e.g. 10% Bleach solution or other commercially-available disinfectant) as soon as feasible after overt contamination of blood or OPIM and after completion of work procedures.

Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled and color-coded (refer to section IV. H - Labels), and closed prior to removal to prevent spillage or protrusion of contents during handling.

Contaminated sharps are discarded immediately, or as soon as feasible, in containers that are closable, puncture-resistant, leak proof on sides and bottoms, and appropriately labeled.
Broken glass is not considered Medical Waste unless it is visibly contaminated with human blood or OPIM. However, this material must be handled with extreme care nonetheless. Employees will use mechanical means, such as tongs or a broom and dustpan, to pick up broken glass, including contaminated glassware. Broken glassware should be placed into the appropriate rigid cardboard glass collection receptacle. Visibly contaminated glass should be placed into a sharps container.

G. Laundry

The identification of contaminated clothing or bed linen is based upon the visible presence of human blood or OPIM. Dirty clothing or bed linen which is not visibly contaminated with blood may be handled and laundered by employees not identified as having occupational exposure to Bloodborne Pathogens. Care must be taken, however, to insure that these employees receive sufficient training to recognize potential contamination so they may defer this work to trained and protected workers.

Items which appear to be contaminated with human blood or OPIM shall only be handled by employees who have received the required training and PPE. If a non-trained employee finds a potentially-contaminated item, they should contact their supervisor, who will call an appropriately trained worker to manage the situation.

Contaminated linen, towels, etc., may be disposed as medical waste, decontaminated with an approved disinfectant, or placed in biohazard disposal bags for laundering by trained workers.

Contaminated laundry or bed linen shall be handled as little as possible with a minimum of agitation, properly bagged and not sorted or rinsed at its point of origin, placed and kept in appropriately-labeled and fluid-resistant containers by the generating department (biohazard disposal bags are suitable for this purpose), and washed with detergent and water at a temperature of not less than 160 degrees Fahrenheit for at least 25 minutes.
Employees responsible for handling contaminated clothing or bed linen shall utilize PPE to minimize potential for exposures. At a minimum, appropriate gloves must be utilized when handling contaminated clothing or bed linen. If aerosolization of potentially-contaminated materials is likely (e.g., when removing contaminated clothing from a biohazard disposal bag which contains visible free liquid), the employee must wear a face shield or mask/goggles when handling the clothing.

H. Spill Clean-Up Procedures

Small Spills (<1 ft2)

• Put on gloves before beginning cleaning activities
• A face shield or mask/goggles should be worn if splashing might occur, or if directed by the supervisor, and when decontaminating materials at or above waist level
• Handle contaminated objects as infectious waste or decontaminate with a tuberculocidal disinfectant or 10% bleach solution
• Place contaminated sharp objects into sharps containers
• Spread paper towels over the contaminated surface(s) and liberally apply disinfectant to the paper towels. The disinfectant should remain in contact with the spilled material for the time period specified by the manufacturer before continuing with decontamination procedures
• Pick up the paper towels, and wipe the surface with disinfectant-dampened paper towels until all visible traces of the contaminant are removed
• After removal of all visible material, re-wipe the surface with clean paper towels and disinfectant, and allow surface to dry
• Place cleanup materials that have touched the contaminated surface (including disposable gloves) into a disposal bag, and place bag in dumpster or trash bins

Larger Spills (>1 ft2)

Larger spills usually require more vigorous methods of cleanup, and therefore more PPE.

• If there is a likelihood of splashing, wear protective gloves and faceshields or masks/goggles
• If strenuous hand activity is anticipated (e.g., mopping), use approved utility gloves
• If cleaning efforts are likely to cause splashing of clothing or if directed by the supervisor, fluid-resistant coveralls or aprons should be worn. Disposable clothing should be discarded into biohazard disposal bags. Disinfect all reusable equipment with disinfectant
• If an individual’s clothing becomes contaminated with human blood or OPIM, remove it as soon as possible, place in a biohazard disposal bag, and deliver to the supervisor for proper laundering

I. Labels and Signage

Biohazard warning labels, which are predominantly fluorescent orange or orange-red and include the universal biohazard symbol, shall be attached to all containers of biological waste, refrigerators and freezers containing blood or OPIM, equipment that has been contaminated with human blood or OPIM if not decontaminated immediately and other containers used to store, transport or ship blood or OPIM. Additionally, biohazard warning signs shall be posted at the entrance to laboratories and other work areas where such hazards are used or stored.

The appropriate Lab Materials Manager, Course Master, and/or PI is responsible for ensuring that warning labels are affixed or appropriate biohazard bags are used as required.

Employees and students are to notify EH&S if they discover regulated waste containers, refrigerators containing blood or OPIM, or contaminated equipment, or other material without proper labels.

The only exception to this requirement is that red bio bags or containers for waste may be substituted for labels.

V. Medical Surveillance

The St. Louis College of Pharmacy is fully compliant with all applicable laws and regulations pertaining to confidentiality.

A. Hepatitis B Vaccination

The St. Louis College of Pharmacy will provide training to employees on hepatitis B vaccinations, addressing safety, benefits, efficacy, methods of administration, and availability.

As a condition of admission to STLCOP, students must submit a Student Health Record (SHR), which includes immunization and vaccination history. This information is assessed and verified prior to their beginning any professional practice curriculum.

The hepatitis B vaccination series is available at no cost after initial employee training and within 10 days of initial assignment to all employees with a reasonably anticipated occupational exposure to bloodborne pathogens and those identified in section III of this ECP.

Vaccination is encouraged for all community members unless documentation exists that they have previously received the series, antibody testing reveals that they are immune, or medical evaluation shows that vaccination is contraindicated.

Vaccination can be provided to all STLCOP stakeholders by:

Concentra Urgent Care        Barnes Care                            SLU Student Health
6542 Manchester Road        5000 Manchester Ave       3518 Laclede Ave.
St. Louis, MO 63139              St. Louis, MO 63110            St. Louis, MO 63103
Phone: (314) 647-0081       Phone: (314) 747-5800     Phone: (314) 977-2323

If an employee declines the vaccination, the employee must sign a declination form (Appendix A). Employees who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the vaccination is kept in the employee’s Human Resource Benefit Folder.

Following the medical evaluation, a copy of the health care professional’s written opinion will be obtained and provided to the employee within 15 days of the completion of the evaluation. It will be limited to whether the employee requires the hepatitis vaccine and whether the vaccine was administered.

B. Post-Exposure Evaluation and Follow-Up

An exposure incident is defined as “a specific mucous membrane, broken skin, or puncture contact with blood or OPIM.”

STLCOP students and employees working at any non-STLCOP facility should review that organizations’ Exposure Control Plan to familiarize themselves with site-specific controls and to ensure they are protected and covered under the plan. If an exposure incident occurs off-campus to a student or employee working at a partner organization as a College representative, the affected individual will default to that site’s ECP if available and applicable. In the event the site’s ECP is inadequate or does not protect the STLCOP member to an equivalent degree of this ECP, then the STLCOP ECP will be followed.

In the event of an exposure incident on campus, any affected employee or student may contact the 24-Hour Exposure Hotline at 1-877-POST-EXP (767-8397) for consultation about the exposure, risks and options.

After administering any necessary initial first aid (e.g. cleaning the wound, flushing eyes or other mucous membrane, etc.), the affected person will immediately notify their supervisor or instructor, who is responsible for submitting an Incident Report form, notifying the Office of Emergency Management and Environmental Health & Safety of the exposure incident, and contacting Security Services at (314) 446-7233 to arrange transport if needed or requested by the affected person.

If the exposure incident occurs during business hours, affected persons may be transported to Concentra Urgent Care – Midtown (6542 Manchester Road, St. Louis, MO 63139) or Barnes Care (5000 Manchester Avenue, St. Louis, MO 63110) for immediate and confidential medical evaluation and follow-up by a health care professional.

Following the initial triage, STLCOP will ensure the following activities occur:

• Document the routes of exposure and how the exposure occurred
• Identify and document the source individual (unless it can be established that identification is infeasible or prohibited by state or local law)
• After obtaining consent, collect exposed person's blood as soon as feasible after exposure incident, and test blood for HBV, HCV, and HIV serological status
• Obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV, and HBV infectivity
Note: If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed
• Assure that the exposed person is provided with the source individual's test results and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual (e.g., laws protecting confidentiality)
• If the employee or student does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days; if the exposed employee or student elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible

The Office of Emergency Management and Environmental Health & Safety will ensure that the health care professional evaluating an employee or student after an exposure incident receives the following:

• The route and circumstances of exposure
• Relevant medical records, including vaccination status
• A description of the employee’s job duties, relevant to the exposure incident
• If and when possible, the results of the source individual’s blood test

The Office of Emergency Management and Environmental Health & Safety will assist in providing the student or employee with a copy of the evaluating health care professional’s written opinion, if not already done so by the professional within 15 days after the completion of the evaluation.

Refer to Appendix B: Exposure Incident Flow Chart for an illustrated process to follow in the event of an exposure incident.

VI. Evaluation of Circumstances Surrounding an Exposure Incident

The Office of Emergency Management and Environmental Health & Safety is responsible for reviewing the circumstances of exposure incidents, with assistance from the Lab Materials Manager (or other supervisory personnel) where the incident occurred. The review will take into consideration the following:

• Engineering controls in use at the time of the incident
• Work practices in use at time of the exposure incident
• A description of the device being used, if applicable (including type and brand)
• Personal protective equipment or clothing used at the time of the exposure incident (gloves, eye shields, etc.)
• Location of the incident
• Procedure being performed when the exposure incident occurred
• Employee or student’s training

Should the review of the circumstances surrounding an exposure incident reveal a need for changes in practices and/or procedures to eliminate or minimize future exposures, the ECP will be revised. Changes to the ECP could include, but are not limited to, implementing safer devices or providing additional training. When revisions are necessary, the Office of Emergency Management and Environmental Health & Safety will ensure that appropriate changes are made to the ECP and will notify affected students and employees of the changes.

VII. Stakeholder Training

All employees who have a potential occupational exposure to bloodborne pathogens receive initial and annual training, meeting the requirements set forth in 29 CFR 1910.1030. The Office of Emergency Management and Environmental Health & Safety has developed a comprehensive BBP-specific training lesson, provided online to employees at the time of initial assignment and when changes occur in job functions or tasks that affect the occupational exposure of an employee, as well as annually thereafter.

Additionally, individual course instructors are responsible for assessing the need for student BBP training and mandating training when necessary. The Office of Experiential Education is responsible for assessing the need for and mandating BBP training for students involved in pharmacy practice experiences.
All students and employees have access to the BBP training lesson via Moodle, which includes information on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the following elements:

• Access to and explanation of OSHA Standard 29 CFR 1910.1030
• Explanation of this ECP and instructions on how to obtain a copy
• How to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident
• The use and limitations of engineering controls, work practices, and PPE
• An explanation of the types, uses, location, removal, handling, decontamination and disposal of PPE
• An explanation of the basis for PPE selection
• Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge
• Information on the appropriate actions to take and who to contact in an emergency involving blood or OPIM
• An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the available medical follow-up
• Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee or students following an exposure incident
• An explanation of the signs and labels and/or color coding required by the standard and used at STLCOP
• Information on how to pose questions to the training developer

Information about training, or its contents, is available from:

St. Louis College of Pharmacy
Office of Emergency Management and Environmental Health & Safety
4588 Parkview Place
St. Louis, MO 63110
Telephone: 314-446-8133

VIII. Record Keeping

A. Training Records

Training records will be maintained by the Office of Emergency Management and Environmental Health & Safety and shall include the:

• Dates of training sessions
• Contents of training
• Names and qualifications of persons conducting the training
• Names and College role of all persons who have received the training

Training records will be maintained for three years from the date on which the training occurred. Employee and student training records are provided upon request to the student, students’ site, preceptor, course coordinator, employee or the employee’s authorized representative within 15 working days. Such requests should be addressed to the Office of Emergency Management and Environmental Health & Safety.

B. Medical Records

Medical records will be maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, “Access to Employee Exposure and Medical Records.”
The STLCOP Department of Human Resources is responsible for maintenance of the required medical records. These confidential records are kept on campus for at least the duration of employment plus 30 years. These records include:

• Name and social security number of the employee
• A copy of the employee’s hepatitis B vaccination status including dates of vaccinations and relevant supporting records
• A copy of all results of examinations, medical testing and follow-up procedures
• A copy of any healthcare professional's written opinion
• A copy of any exposure incident evaluation reports

Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to the Department of Human Resources

Student Health Records (SHRs) for freshman, sophomore and junior students are maintained by the Dean’s Office, and by the Office of Experiential Education for all other students. These confidential records are kept on campus for at least the duration of a students’ academic career, and may include:

• Name and social security number of the student
• A copy of the student’s immunization status including dates of vaccinations and relevant supporting records
• A copy of all results of examinations, medical testing and follow-up procedures
• A copy of any exposure incident evaluation reports

C. OSHA Records

An exposure incident is evaluated to determine if the case meets OSHA’s Recordkeeping Requirements (29 CFR 1904). This determination and the recording activities are done by the Department of Human Resources

D. OSHA Sharps Injury Log

In addition to the 29 CFR 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in a Sharps Injury Log. All incidences must include at least:

• Date of the injury
• Type and brand of the device involved (syringe, suture needle, etc.)
• Department or work area where the incident occurred
• Explanation of how the incident occurred

This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.


Please refer to Section II. Program Administration for more information.



Emergency Management Coordinator

Implementation, maintenance and updates of the ECP; developing and facilitating bloodborne pathogen training and documentation; coordinating follow-up and evaluation after exposure incidents

Director of Human Resources

Maintaining employee medical records, OSHA records, Sharps Injury Log

Lab Materials Manager/Supervisor

Providing and maintaining lab-specific PPE, engineering controls, labels and biohazard collection receptacles; completing Incident Report form following exposure incident


OSHA Standard 29 CFR 1910.1030: “Occupational Exposure to Bloodborne Pathogens”

OSHA Standard 29 CFR 1910.1020: “Access to Employee Exposure and Medical Records”

STLCOP Personal Protective Equipment (PPE) Policy

Policy Contacts:


Contact Information

Emergency Management Coordinator

Office: (314) 446-8133

Emergency: (618) 973-3944


Vice President Operations

Office: (314) 446-8375

Emergency: (314) 210-1104