Bloodborne Pathogen Policy & Exposure Control Plan

Summary of Policy

This policy applies to all non laboratory Dartmouth employees who are likely to encounter BBPs during routine job duties.

Affected Parties

All Groups

Policy Statement

For Non-­Research Employees

Prepared in compliance with 29 CFR 1910.1030

Exposure Control Plan (ECP) for Bloodborne Pathogens

Dartmouth College is committed to providing a safe and healthful work environment for all employees. In pursuit of this endeavor, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens."

The ECP is a key document to assist Dartmouth College in implementing and ensuring compliance with the standard, thereby protecting our employees. This ECP includes:

  • Determination of employee exposure;
  • Implementation of various methods of exposure control, including:
    • Universal precautions,
    • Engineering and work practice controls,
    • Personal protective equipment, and
    • Housekeeping
  • Hepatitis B vaccination;
  • Post-exposure evaluation and follow-up;
  • Communication of hazards to employees and training;
  • Procedures for evaluating circumstances surrounding an exposure incident.

The implementation of the Bloodborne Pathogen standard is discussed in this ECP.

Administrative Duties

The Dartmouth College Environmental Health and Safety Office (EH&S) is responsible for the implementation of the ECP. This office will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasks and procedures. Dartmouth EH&S is responsible for ensuring that systems are in place for all required medical actions required and that appropriate employee health and OSHA records are maintained. Lastly, this office is responsible for providing bloodborne pathogen training, maintaining documentation of training, and making the written ECP available to employees and regulatory agencies.

Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP.

Supervisors will maintain and provide all necessary personal protective equipment (PPE) as required by the standard.

Scope: This policy applies to all non laboratory Dartmouth employees who are likely to encounter BBPs during routine job duties.

Laboratory researchers and staff are covered under the Emergency Response and Biohazard Exposure Control Plan. Dick's House employees are covered by their internal ECP.

Employee Exposure Determination

The following is a list of all job classifications covered under this policy that have the potential for occupational exposure:

  • Facilities, Operations, and Management Custodians
  • Office of Residential Life Custodians
  • Safety and Security Personnel
  • Dick's House Employees
  • Athletic Department Personnel

Methods of Implementation and Control

Universal Precautions

All employees will utilize universal precautions; all blood and bodily fluids should be assumed to be potentially infectious and, consequently, appropriate protective measures should be taken in all cases.

Exposure Control Plan

Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual refresher training. All employees have an opportunity to review this plan at any time during their work shifts by contacting the Dartmouth Environmental Health and Safety Office. The ECP is readily available on the web and by request.

The Dartmouth EH&S Office is responsible for reviewing and updating the ECP periodically if necessary to reflect any new or modified tasks and procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

Bloodborne Pathogens (BPPs) are microorganisms such as viruses or bacteria that are found in blood and body fluids and can cause disease in people. Those of most concern are Human Immunodeficiency Virus (HIV), Hepatitis B Virus, and Hepatitis C Virus.

Exposure to BPPs could occur through contact with any of the following:

  • Blood
  • Saliva
  • Feces
  • Other Potentially Infected Material

General Work Procedures

  1. Engineering and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens.
    1. If an encounter with a discarded hypodermic needle occurs, employees shall contact their supervisor.
    2. Exercise caution with any contaminated sharp object.
    3. Do not pick up any contaminated broken glass with your hands.
  2. Do not eat, drink, smoke, handle contact lenses or apply cosmetics in areas where exposure to bloodborne pathogens is possible. Do not store food and drinks in refrigerators or cabinets where blood and other potentially infectious materials are stored.
  3. Perform procedures involving blood and other potentially infectious materials in such a manner that will minimize splashing or spraying.

Personal Protective Equipment (PPE)

PPE is provided to each of our employees at no cost. Training is provided by the Dartmouth EH&S Office concerning the use of the appropriate PPE for the tasks or procedures employees will perform.

The types of PPE available to employees are as follows: 1) Gloves: Gloves are to be worn by all employees directly handling blood or OPIM and when cleaning contaminated surfaces. Disposable, single-use nitrile gloves are required and are to be changed frequently; gloves must be replaced when visibly soiled, torn, or punctured; 2) Safety Glasses/Shields: Safety glasses are recommended at all times. Safety goggles are recommended when splash potential is high.

Nitrile gloves and additional PPE may be obtained through a custodial squad leader or departmental supervisor. EH&S may be contacted for assistance in obtaining PPE if the supervisor is unable to obtain the proper PPE.

Each employee using PPE must observe the following precautions: 1) Primarily, gloves are never a substitute for thorough hand washing. Hands should be thoroughly washed before the wearing of gloves, and after glove removal; 2) Wash your hands as soon as possible after handling potentially infectious materials, and after removing protective clothing and equipment. 3) Always check PPE for damage or tearing before use. 4) Cover any cuts with bandages before putting on gloves. 5) When removing gloves, be sure that bare skin does not come in contact with the exterior of the gloves.

Disposable gloves are not to be re-used and may be discarded in regular trash bins.

Disposal of blood contaminated material shall be performed in accordance with the guidelines provided in the Blood Spill Kits available in each custodial work room. 

Hepatitis B Vaccination

Information concerning the Hepatitis B Virus (HBV) and HBV vaccines may be obtained by calling Dartmouth EH&S at 646-1762. This office will provide training to employees on Hepatitis B vaccinations that will address the safety, benefits, efficacy, methods of administration, and availability of the vaccinations.

The Hepatitis B vaccination series is available at no cost after training and within 10 days of initial assignment to employees identified in the exposure determination section of this plan. Vaccination is encouraged unless:

  1. Documentation exists that the employee has previously received the series,
  2. Antibody testing reveals that the employee is immune, or
  3. Medical evaluation shows that vaccination is contraindicated.

However, if an employee chooses to decline vaccination, the employee must sign a declination form.  Employees who decline may request and obtain the vaccination at a later date at no cost. See Appendix 1 for the vaccination consent/declination document.

Post-exposure Evaluation and Follow-Up

Immediate Response:

  1. Skin Exposure: immediately remove contaminated personal protective equipment or clothing and wash the contaminated area with an iodine solution or antibacterial soap and copious water for 15 minutes.
  2. Eye Exposure: Flush the eye with water for at least 15 minutes at an eyewash station.

Should an exposure incident occur:

  1. Notify supervisor if immediately available.
  2. Report to the Occupational Medicine Department at DHMC between 7:30 am and 4:00 pm.
  3. After hours, report to DHMC emergency room.

Important Contact Information:
DHMC Occupational Medicine: (603) 653-3850
For emergency transport, dial 911

An immediately available confidential medical evaluation and follow-up will be conducted by Dick's House or the Department of Occupational Medicine, Dartmouth-Hitchcock Medical Center.

Administration of Post-Exposure Evaluation and Follow-up
The Dartmouth College EH&S Office ensures that health care professional(s) responsible for an employee's Hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA's bloodborne pathogens standard.

Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

Department Supervisors and EH&S officers will conduct investigations into exposure incidents. If it is determined that revisions need to be made to this ECP, the Dartmouth EH&S Office will ensure that appropriate changes are implemented. Furthermore, retraining will be offered if it deemed necessary due to the cause of the accident.

Employee Training

Each employee who has the potential for occupational exposure to bloodborne pathogens receives training conducted by Dartmouth EH&S or by completing the online training course available through BioRAFT at

The Dartmouth EH&S Office provides OSHA mandated bloodborne pathogen training. It is the responsibility of each supervisor to ensure all personnel under their supervision complete this required training.

Hepatitis B Vaccine Form:
All employees who may be exposed to blood or "other potentially infectious material" (OPIM) during the routine course of their work must complete the following Hepatitis Vaccine Form. This form is filed with the Dartmouth EH&S Office.

Policy ID


Effective Date

January 31, 2016


Campus Services

Office of Primary Responsibility

Office of Environmental Health & Safety (EHS)

Last Reviewed Date

July 5, 2022

Next Review Date