URP: I.23.d Bloodborne Pathogens


The Texas Woman’s University Bloodborne Pathogen Regulation and Procedures are established to protect faculty, staff, students, and guests who are exposed to blood or other potentially infectious materials in the course of their occupation or education at Texas Woman's University (TWU). 



  • Blood: Human blood, human blood components, and products made from human blood
  • Bloodborne Pathogen: Pathogenic microorganisms that are present in human blood and other potentially infectious materials 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).
  • Bloodborne Pathogen Exposure Control Plan (ECP): A plan to protect faculty, staff, students, and guests from bloodborne pathogens. The ECP covers:
    • Responsibilities
    • Exposure determination
    • Methods of Compliance including universal precautions, engineering and work practice controls, personal protective equipment, and waste handling/disposal
    • Hepatitis B and other vaccinations
    • Prevention of transmission while providing health care services where applicable
    • Evaluation and follow-up following accidental exposure to bloodborne pathogens
    • Communication of hazards to employees (warning labeling)
    • Training
    • Annual plan reviews
    • See: http://www.twu.edu/rm/Bloodborne-Pathogens.asp
  • Exposure Control Plan (ECP): The procedures for what to do if exposed to bloodborne pathogens. See Bloodborne Pathogen Exposure Control Plan (ECP).
  • Other Potentially Infectious Materials (OPIM): OPIMs include:
    • Human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid (joint lubricant), pleural fluid (around lungs), pericardial fluid (around heart), peritoneal fluid (around abdomen), amniotic fluid, breast milk, saliva in dental procedures, human cell lines (that are not documented to be free of bloodborne pathogens), any body fluid visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids.
    • Any unfixed tissue or organ (other than intact skin) from a human, living or dead
    • HIV-containing cell or tissue cultures, organ cultures, and HIV, HBV or HBC containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV, HBV or HBC.


TWU Students, Faculty, Staff, and Guest       

TWU Student             

TWU Faculty                               

TWU Staff

TWU Guest

Exposure Incident Procedure Summary

The following is a summary of the required procedures when an employee or student has an “exposure incident” (a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties or as part of a student’s education). For complete instructions, refer to the Post Exposure Evaluation and Follow-Up section of the TWU Bloodborne Pathogen Exposure Control Plan: http://www.twu.edu/rm/Bloodborne-Pathogens.asp 

Following an exposure incident all of the following must be completed:

  1. Cleanse the wound and surrounding area with soap and water (for a puncture, cut or similar incident), and/or flush eyes, nose or mouth with copious amounts of tap water (for a splash to the face).
  2. Report the incident to exposed individual’s supervisor immediately.
  3. Exposure incidents are to be considered urgent medical concerns. The supervisor of the exposed individual must ensure that he/she receive medical attention promptly. The CDC states that post exposure preventive medications are most likely to be effective if administered as soon as possible after the exposure (within hours of the incident, not days). The exposed individual must immediately be sent to a nearby hospital or clinic to receive the postexposure evaluation described below. Students may be sent to Student Health Services in Denton, or to a local clinic or hospital. Employees must be sent to a clinic or hospital within the IMO Med-Select Network if available in the area (call 888-466-6381 or visit www.injurymanagement.com  to find a provider).
    1. The exposed individual must receive a confidential medical evaluation and follow up including identification and documentation of source individual, collection and testing of blood, post-exposure prophylaxis when medically indicated, and appropriate counseling regarding infection status/results of tests/necessary precautions.
    2. The information on the Exposure Incident Reporting Form (see Bloodborne Pathogen website: http://www.twu.edu/rm/Bloodborne-Pathogens.asp ) must be provided to the healthcare professional providing the medical evaluation as soon as possible (but do not delay sending the exposed individual for treatment). This may be accomplished verbally or by using the form, but all information on the form must be provided.
  4. The exposed individual’s supervisor must obtain and provide the individual with a copy of the medical provider’s written opinion within 15 days of completion of the evaluation. This opinion must be limited to the items listed on the Medical Provider’s Written Opinion Form (see Bloodborne Pathogen website for form).
  5. The exposed individual and his/her supervisor must complete the “Employee’s Report of Injury” form (SORM-29) and the “Supervisor’s Report of Incident, Injury or Illness” form (SORM-703) and submit them to TWU Human Resources as soon as possible after the employee receives medical care. see Bloodborne Pathogen website for forms.
  6. If the incident involved a percutaneous injury from contaminated sharps, the DSHS “Contaminated Sharps Injury Reporting Form” must be completed by the supervisor and mailed to the local health department and a copy provided to Risk Management within 10 days of the incident. See Bloodborne Pathogen website for form.


The University shall endeavor to comply with the intent of appropriate federal and state legislation and regulations, including the U.S. Occupational Health and Safety Administration regulations (including 29 CFR 1910.1030), Texas Department of State Health Services regulations (including 25 TAC 96 and 25 TAC 97), the Texas Health and Safety Code (including Chapter 81 Subchapter H and Chapter 85 Subchapter I), and the State Board of Dental Examiners regulations (including 22 TAC 108).


These acts, along with supporting University guidelines, rules, and procedures; as outlined in the TWU Exposure Control Plan (ECP); will provide the standards under which the University will conduct its bloodborne pathogen program.  A copy of the ECP is available in the Risk Management office and on the Risk Management website for inspection and use.


Employees who are exposed to blood or other potentially infectious materials will be offered the Hepatitis B vaccine at no cost within 10 working days of initial assignment. Employees would not be offered the vaccine if the employee has previously received the complete Hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or that the vaccine is contraindicated for medical reasons.  Any employee who declines to receive the Hepatitis B vaccine must sign a Hepatitis B Vaccine Declination Form.  For individuals who decline to receive the vaccination, but later decide to accept the vaccination and are still exposed to blood or other potentially infectious materials, TWU will provide the vaccine at no cost.


Health Professional Students who are exposed to blood or other potentially infectious materials are required to obtain Hepatitis B and other vaccinations, at their own expense, as necessary to protect student health in accordance with the ECP.


Texas Woman's University does not require HIV testing of its employees or students.  However, such testing may be required by some health care agencies with which the University affiliates for clinical education.  Policies related to students and faculty with HIV infection are described in TWU Policy 6.04 – “HIV Infection/AIDS Among TWU Students and Employees”.


Faculty, staff and students who are exposed to blood or other potentially infectious materials are required to use personal protective equipment (PPE) in accordance with the ECP.  PPE required by the ECP will be provided to employees at no cost.


Faculty, staff and students who are exposed to blood or other potentially infectious materials are required to complete training as required by the ECP.  Appropriate training will be provided by the University to all exposed faculty, staff and students.



Article ID: 39637
Tue 9/26/17 12:32 PM
Thu 2/14/19 4:08 PM