1. This policy has been established to address the university's concern for protecting its employees, students, volunteers, and visitors from the risk of infection from bloodborne pathogens, which include but are not limited to Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV), and syphilis. This policy also addresses the services rendered by the university to individuals who experience an exposure to blood or other potentially infectious materials (OPIM) during an occupational or non-occupational related activity. The university has developed procedures to be followed in the event of an accident involving the unprotected exposure to blood or OPIM, whether work related or associated with university sanctioned activities of employees, students, volunteers, or visitors, which causes or offers the potential to cause illness.
2. Additional guidance relative to the university's position on HIV (AIDS) is contained in Executive Memorandum No. 88-11, dated December 12, 1988.

For the purpose of this policy, exposure to HIV or other bloodborne pathogens is categorized as either occupational or non-occupational. The Department of Environmental Health and Safety (EHS) can provide guidance in assigning categories.

1. Accident. The occurrence of an event that results in injury and/or illness to an individual.
2. Blood. Human blood, human blood components, and products made from human blood.
3. Blood or other potentially infectious materials (OPIM).

1. Any human blood or other body fluids (i.e., semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, and amniotic fluid), saliva in dental procedures, and any body fluid that is visibly or could potentially be 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); and,
3. HIV or hepatitis virus-containing cell or tissue cultures, organ cultures, and culture medium or other solutions and blood organs or other tissues from experimental animals infected with HIV or hepatitis viruses.

4. Exposure incident. A specific eye, mouth, other mucus membrane, non-intact skin, or parenteral contact with blood or OPIM that results from the performance of an employee’s duties.
5. Occupational exposure. Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of an employee's duties.
6. Non-occupational exposure. Exposure to blood or OPIM by university students, volunteers, and visitors which occurs while on campus or off campus attending or participating in a university sponsored activity, including but not limited to intramural and recreational sports and activities sponsored by registered student organizations. This category also would be assigned to university employees under the following conditions:

1. The employee is in a non-work status and is exposed to blood or OPIM while attending or participating in a university sponsored activity.
2. The employee is on official work status and becomes exposed to blood or OPIM while conducting non-work activities (i.e., jogging, weight lifting, racquetball, basketball, and swimming).

7. Person-in-charge (PIC). Any person who is responsible for and supervises activities of other people who have occupational or non-occupational exposures as defined in paragraphs 6034.2 e) and f). This person may be a supervisor, principal investigator, department chair, director, or a person in charge of a university sponsored program. A principal investigator planning research activities involving blood or OPIM, in addition to complying with all requirements of this policy, must have an approved biosafety protocol from the Institutional Biosafety Committee prior to initiating such activity.
8. University employee. Faculty, staff, and student employees who receive compensation from the university for their employment and who are covered under Ohio Bureau of Worker's Compensation.

This section addresses an individual's responsibilities and the procedures to be followed for both occupational and non-occupational exposures to blood or other OPIM. Procedures are based on recommendations and/or requirements of the United States Department of Labor (OSHA), the United States Department of Health and Human Services, and the Ohio State Department of Health. Specific references are listed in section 6034.6 of this policy.

1. Occupational exposures

1. The PIC of any university occupational activity planning work with blood and/or OPIM must report such activity prior to commencing work that offers the potential for exposure to blood or OPIM. In specific, the PIC is required to provide the following information to the Department of Environmental Health and Safety and to the Department of Human Resources.

a.) A list of job classifications in which all personnel in those classifications have "occupational exposure."

b.) A list of job classifications in which some employees in those classifications have "occupational exposure."

c.) A list of all tasks and procedures or groups of closely related tasks and procedures, in which "occupational exposures" occur, that are performed by employees listed in paragraphs (a) and (b) above. Exposure determination is made without regard to the use of personal protective equipment.

2. Employees involved in the work activity, including the PIC, must receive their initial training within ten working days following employment or assignment to a work activity covered by the Bloodborne Pathogen Program. Annual refresher training also is mandatory. EHS will conduct both the initial and refresher training. Training by EHS does not negate the PIC's responsibility for instructing his/her staff on specific procedures in the workplace.
3. During initial training, EHS will provide the PIC with a copy of the university's Exposure Control Plan for Bloodborne Pathogens and a copy of the OSHA Bloodborne Pathogen Standard (29 CFR 1910.1030). It is the PIC's responsibility to ensure that all activities involving blood and/or OPIM are conducted in compliance with the contents of the university’s plan.
4. The PIC is required to report to EHS any accidents in which an employee experiences an unprotected exposure to blood and/or OPIM [refer to paragraph 6034.2 c) for the definition of blood and/or OPIM]. Specific guidelines for submitting an accident report are given in paragraph 6034.4 a) and in Wright Way Policy 6032 (Reporting Injuries and Illnesses).

2. Non-occupational exposures

1. Employees, students, volunteers, and visitors exposed to blood and/or OPIM in a non-occupational incident while attending or participating in any university sponsored activity will be offered, at no cost to the participant, the post-exposure medical monitoring program.
2. University police officers or Student Health Services employees responding to accidents or incidents involving non-occupational exposure to blood and/or OPIM will inform any exposed individual of the medical monitoring program. For off-campus facilities or for activities conducted off campus, the PIC will be responsible for informing the participant.
3. The university police officer, Student Health Services employee, or the PIC is responsible for telephone notification of the incident to EHS and is responsible for completing a Wright State University Incident Report form. Specific guidelines for submitting the Incident Report form are provided in paragraph 6034.4 b) and in Wright Way Policy 6032 (Reporting Injuries and Illnesses).

3. Responsibilities of the Department of Environmental Health and Safety

1. Maintain all occupational health records.
2. Schedule all personnel for occupational health appointments.
3. Assist in the investigation of all exposure accidents/incidents.
4. Provide to the Department of Human Resources the names of all employees who decline the Hepatitis B vaccination series.
5. Provide initial and refresher training on bloodborne pathogens.
6. Maintain training records for all employees covered by the Bloodborne Pathogen Program.
7. Notify appropriate parties of changes in regulatory requirements.
8. Review and revise the university’s Exposure Control Plan for Bloodborne Pathogens at least annually and/or when changes occur.

4. Responsibilities of the Department of Human Resources

1. Maintain a list of job descriptions in which all employees have occupational exposures to blood and/or OPIM.
2. Maintain a list of job descriptions in which some employees have occupational exposures to blood and/or OPIM.
3. Maintain a list of all tasks and procedures or groups of closely related tasks and procedures performed by employees listed in paragraphs 6034.3 d) 1) and 2).
4. Maintain a list of employees who have declined the Hepatitis B vaccination series.

1. Accidents/incidents involving occupational exposures

1. The PIC is responsible for notifying the Department of Environmental Health and Safety by telephone (775-2215) of any occupational accident/incident that results in an employee's exposure to blood and/or OPIM. Notification is to be made as soon as possible but no later than 9 am of the next normal workday.
2. The PIC is responsible for completing, signing, and submitting the employee injury and illness report (OSHA Form 101) to EHS for all occupational accidents or incidents which result in an employee's exposure to blood and/or OPIM. OSHA Form 101 must be completed in its entirety. An incomplete submittal will be returned to the supervisor of the employee who completed the form. OSHA Form 101 is to be submitted to EHS as soon as possible but in no case later than three workdays following the date of the accident/incident.
3. Additional information for reporting accidents/incidents is contained in Wright Way Policy 6032 (Reporting Injuries and Illnesses). PICs are encouraged to become familiar with Policy 6032.

2. Accidents/incidents involving non-occupational exposures

1. University police officers, Student Health Services employees, or PICs of university sponsored activities are responsible for notifying the Department of Environmental Health and Safety by telephone (775-2215) of any exposure accident/incident. Notification is to be made as soon as possible but no later than 9 am of the next normal workday.
2. University police officers, Student Health Services employees, or PICs of university sponsored activities are responsible for submitting the Wright State University Incident Report form to EHS for accidents/incidents involving the exposure of students, volunteers, and visitors to blood and/or OPIM. The form should be signed by the participant whenever possible. Reports are due to EHS as soon as possible but in no case later than three workdays following the date of the accident/incident.
3. Additional information for reporting accidents/incidents is contained in Wright Way Policy 6032 (Reporting Injuries and Illnesses). University police officers and Student Health Services employees are encouraged to become familiar with Policy 6032.

1. The Department of Environmental Health and Safety is responsible for scheduling all pre-employment, baseline, periodic, and post-exposure tests for employees in the occupational exposure category. EHS also will schedule all post-exposure tests for individuals experiencing non-occupational exposures to blood and/or OPIM.
2. The medical monitoring program for employees with occupational exposures will be addressed during the mandatory training sessions. Individuals experiencing a non-occupational exposure to blood and/or OPIM while attending or participating in a university sponsored activity will be offered the following medical services at no cost to the individual.

1. Blood test to monitor for HBV.
2. Blood test to monitor for HIV antibodies.
3. HBV booster immunizations as directed by the attending physician.
4. Medical counseling as directed by the attending physician.

3. The attending physician shall be appointed by the university.
4. Any discussion or reports between physician and patient relative to the presence or absence of disease is confidential, and such information is not provided to EHS.

1. Center for Disease Control (Department of Labor/Department of Health and Human Services), Joint Advisory Notice, Protection Against Occupational Exposure to Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV), October 30, 1987.
2. The Code of Federal Regulations, Title 29, Part 1910, Subpart Z, Section 1910.1030: Bloodborne Pathogens.
3. Ohio Department of Health, Policy Guidelines on AIDS and Other Bloodborne Diseases for Law Enforcement Personnel.
4. Wright State University, Exposure Control Plan for Bloodborne Pathogens, as revised.