Skip to Content



  1. Purpose and Applicability
  2. Definitions and Scope
  3. Roles and Responsibilities
  4. Procedures
  5. Key References and Resources



This policy is designed to minimize all exposure to blood and other potentially infectious material, as defined in section 2.0.


This policy ensures that training and the hepatitis B vaccination series is made available to those individuals who are exposed to bloodborne pathogens (BBP) in the course of their University duties.


This policy applies to faculty, staff and work-study students who may reasonably anticipate occupational exposure to bloodborne pathogens, including research and clinical personnel, custodial staff, facilities staff, police and security, and others.

back to top



"Blood" means human blood, human blood components, and products made from human blood.


"Bloodborne pathogens" means pathogenic microorganisms that are present in human blood and can cause disease in humans including Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV).


"Occupational exposure" means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.


"Other potentially infectious materials" includes, but is not limited to, the following human bodily fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, amniotic fluid, saliva in dental procedures; any mix of body fluids where it is impossible to differentiate between fluids; any unfixed human (living or dead) tissue or organ (other than intact skin).


"Exposure Incident" means specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious material in the workplace.


"Standard Precautions" means treating all human source material as if it is potentially infectious.

back to top



The Office of Environmental Health and Radiation Safety (EHRS) provides instruction and training on safe work practices, conducts routine inspections of work areas, investigates accidents, and recommends preventive/corrective actions. EHRS assists departments with the OSHA Bloodborne Pathogens Standard compliance.


The Institutional Biosafety Officer (BSO) is responsible for the overall BBP program, including the development of an Exposure Control Plan template document, annual review and update of the Exposure Control Plan and related materials and development and presentation of BBP training. The Biosafety staff is responsible for the daily implementation of the BBP program as it applies to laboratories, including training. The Biosafety staff also support other University operations by developing and providing BBP training and emergency response.


Principal Investigators (PI) and area supervisors are responsible for ensuring annual training for any of their staff that may reasonably anticipate exposure to BBP; establishing safe work practices and procedures; annually updating the Exposure Control Plan template document (See 4.1 below).


Employees are responsible to attend introductory BBP training and annual online BBP update training, follow established safe work practices and procedures and report any exposure incidents to their supervisor.


Each lab group and/or Facilities Services housekeeping staff is responsible for cleaning minor BBP spills. EHRS is available to assist with emergency response.


Occupational Medicine in the Hospital of the University of Pennsylvania,University of Pennsylvania Medical Center (HUP/UPMC) is responsible to administer the hepatitis B vaccine; provide employees involved in exposure incidents with the standard of care, including counseling and the administration of post-exposure prophylaxis; and maintain all medical records in accordance with all applicable regulations.

back to top


4.1 Written Plan

EHRS makes available a written Exposure Control Plan template document, which describes the BBP programs in detail. This document is reviewed and updated annually by EHRS.

4.2 Exposure Control

A variety of controls are in place to effectively eliminate or minimize the risks of infection, including standard precautions, engineering controls and work practices, personal protective equipment, sanitary conditions, infectious waste management, laundry procedures, and labels and signs. These controls are detailed in both the written plan and in employee training.

4.3 Training

Training is provided for personnel that are affected by the BBP standard by the Biosafety staff.

4.4 Hepatitis B Vaccination

Free hepatitis B vaccine is available to all employees who may have occupational exposure to bloodborne pathogens. Occupational Medicine administers the vaccine. Any employee who refuses the vaccine is asked to sign a declination waiver.

4.5 Bloodborne Pathogen Spills

It is the responsibility of lab personnel to routinely clean up minor spills, accidents, or incidents involving blood or other potentially infectious material in the laboratory. Facilities Services housekeeping staff is responsible to clean up minor spills in lavatories and dormitory spaces. Large or complicated spills should be reported immediately to EHRS. EHRS will arrange for prompt cleanup.

4.6 Exposure Incidents

Employees who are involved in exposure incidents during normal working hours should be directed to report immediately to Occupational Medicine for medical attention. Students who are involved in exposure incidents should be directed to report to Student Health Service. Visitors are referred to the Emergency Department at HUP/UPMC. After hours, employees, students and visitors are referred to the Emergency Department at HUP/UPMC.

4.7 Recordkeeping

EHRS maintains training records for three years from the date of training. Vaccination declination waivers are also on file at EHRS. Training records include the contents of the training session, and an attendance sheet that includes the names, job titles and dates of those trained. Occupational Medicine maintains all medical records on employees including vaccinations and occupational exposure incidents.

back to top


The following references and resources may be obtained from the Office of Environmental Health and Radiation Safety and are available on the EHRS Biosafety web page

University of Pennsylvania Exposure Control Plan

OSHA 29 CFR 1910.1030 Bloodborne Pathogen Standard

OSHA Hepatitis B Vaccination Declination Statement

University of Pennsylvania Biological Safety Manual

Infectious Agents MSDS

back to top