OSHA Field Safety and Health Management System (SHMS) Manual


  1. Purpose

    This program establishes a uniform policy and guidelines for protecting OSHA employees from bloodborne pathogens and other potentially infectious materials (OPIM).

  2. Scope

    This program applies to all staff of the OSHA's Field offices. OSHA does not anticipate its employees will have occupational exposure to blood or OPIM.

  3. References
    1. CPL 02-02-077, Bloodborne Pathogens Exposure Control Plan and Guidance on Post-Exposure Evaluations for Federal OSHA Personnel, dated 09/27/2010.

    2. Memorandum of Understanding Between The U.S DOL and NCFLL, dated 10/21/2010.

  4. Exposure Control Plan
    1. Exposure Determination

      OSHA does not anticipate that its employees will have occupational exposure to blood or other potential infectious materials (OPIM). OPIM is defined as: (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); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. The standard defines occupational exposure as “reasonably anticipated skin, eye, mucous, membrane or parental contact with blood or other potentially infectious materials that may result from performance of the employee’s duties.”

      CSHOs and other field personnel conduct investigations at sites where blood and OPIM are present. However, OSHA does not reasonably anticipate that these employees’ routine tasks will result in contact with blood or OPIM.

    2. Hazard Assessment

      CSHOs and other personnel with field duties (hereafter referred to collectively as “field personnel”) shall take necessary precautions to avoid contact with blood and OPIM and shall not participate in activities, nor enter areas that will require them to come into contact with blood or OPIM or with needles, instruments or surfaces that are contaminated with blood or OPIM. If field personnel believe that the investigation may result in a potential exposure to blood or OPIM, they must contact their supervisor immediately upon making this determination. The supervisor will contact the Area Director who, in turn, will contact the Regional Administrator (or designee) to discuss the situation. Field personnel will not enter an area where potential exposure to blood or OPIM could occur without prior approval from the Regional Administrator (or designee). In those exceptional circumstances where an exposure incident does occur as part of an investigation (e.g. a CSHO inadvertently handles items that have become contaminated with blood or OPIM), the employee shall immediately decontaminate the affected area following the procedures in section V.A.1., and then contact a supervisor to discuss the situation and how to obtain the post-exposure evaluation.

    3. Methods of Implementation and Control

      1. Universal Precautions and Work Practices. Field personnel should consider all blood and OPIM to be infectious for HIV, HBV, and other bloodborne pathogens. Under circumstances where differentiation of body fluid types is difficult or impossible, all body fluids should be considered to be potentially infectious materials.

        Field personnel are not to handle or touch objects that are contaminated, as defined by 29 CFR 1910.1030(b). They shall not reach into or otherwise place any parts of their bodies into the trash can or laundry bag where regulated waste or contaminated laundry as defined by 29 CFR 1910.1030(b) may be present.

      2. Bloodborne Pathogen Training. OSHA field personnel will be given bloodborne pathogen training at the time of initial assignment to field duties and annually on the elements included on 29 CFR 1910.1030(g)(2) except for 1910.1030(g)(2)(vii)(I). The training required by 1910.1030(g)(2)(vii)(I) on the hepatitis B vaccine need only include information on its efficacy, safety, method of administration and the benefits of being vaccinated. The trainer must be familiar with the Bloodborne pathogens standard. The Regional Administrator and Area Directors who supervise employees with field duties are responsible for ensuring that this training is provided.

      3. Voluntary Hepatitis B Vaccination. Firm management commitment to avoid contact with blood and other potentially infectious materials is the primary control method to prevent exposing field personnel to Hepatitis B and other bloodborne pathogens. In addition, Hepatitis B immunization is a safe and effective way to prevent Hepatitis B infection and its serious consequences. OSHA will provide interested field personnel with Hepatitis B immunization, on a voluntary basis, for health promotion and preventive care in accordance with the Memorandum of Understanding between OSHA and NCFLL dated October 21, 2010.

        Hepatitis B vaccination is available to Department of Labor (DOL) employees through the DOL national health services agreement with Federal Occupational Health (FOH). Employees are encouraged to seek their physician or other qualified health care provider’s advice for any questions regarding their medical condition(s) and also review the Center for Disease Control (CDC) Hepatitis B Vaccination Information Statement before requesting the vaccination.

        Employees interested in receiving Hepatitis B vaccination should contact their local FOH unit. It is important to make arrangements before arriving for an appointment since most FOH units do not keep Hepatitis B vaccine in stock. To get the Hepatitis B vaccination, employees must present their valid DOL Identification Badge at the FOH unit. After the first Hepatitis B vaccination is given, the FOH unit will inform employees when to schedule appointments for the second and third injections to complete the vaccine series.

        Alternatively, interested OSHA personnel that are covered by OSHA’s Field SHMS (e.g. in the NCFLL bargaining unit) but do not have an FOH unit in their local area may contact their Regional Office of Administrative Programs to learn how to obtain the vaccine from a local private healthcare provider. Not all healthcare providers offer Hepatitis B vaccinations and accept credit card payments. The Regional Office of Administrative Programs can arrange with the private healthcare provider’s office to pay for the three injections necessary to complete the Hepatitis B vaccination using the Regional Office’s credit card.

        For additional information about the Hepatitis B Vaccination please see the Center for Disease Control Guidance at: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html

      4. Post-exposure Evaluation and Follow-up. OSHA shall provide post-exposure evaluation and follow-up, and post-exposure prophylaxis when medically indicated to any employee who suffers an exposure incident as defined by 29 CFR 1910.1030(b), while performing work assignments. All medical evaluations and procedures are to be made available at no cost to OSHA personnel at a reasonable time and place, and under the other conditions set forth in 29 CFR 1910.1030(f). Post-exposure evaluation and follow-up will be offered by OSHA to employees who experience an exposure to blood or OPIM (as defined in 29 CFR 1910.1030) while on duty when acting as a Good Samaritan to others who have sustained a laceration, a nosebleed, or similar incidents.

      5. Recordkeeping: Training Records. Training records are to contain all information specified on 29 CFR 1910.1030(h)(2) and will be maintained for 3 years from the date on which the training occurred. Training records will be held by the office at which training took place.

  5. Procedures for Unforeseen Contact with Blood or Other Potentially Infectious Material (OPIM)
    1. Work Practice Controls

      1. Intact skin contact with blood or OPIM

        Employees are to wash their hands and any other affected skin with soap and water immediately or as soon as feasible if there has been skin contact with blood or OPIM. As soon as possible, the employee must notify his/her supervisor regarding the exposure. If the OSHA employee and supervisor are not able to determine the exposure was definitely not an exposure incident (e.g. the employee has an open wound, chapped hands), the supervisor should immediately contact the Regional Administrator or their designee. The Regional Administrator or their designee will then contact the Director of the Office of Occupational Medicine and Nursing (OOMN) within 30 minutes to determine if post-exposure evaluation is warranted. Each Region and Office will develop procedures for notification and payment during and after business hours.

        Antiseptic towelettes will be provided by the Regional Offices to field personnel. These towelettes are to be carried on all inspections, in the event soap and running water may not be immediately available, and used in the unlikely event that contact of any skin surface with blood or other potentially infectious material occurs. Whenever antiseptic towelettes are used, hands or other skin surfaces are to be washed as soon as feasible with soap and running water.

        Used antiseptic towelettes should be disposed of as non-regulated trash except in a very rare circumstance where they become contaminated to the extent (see 1910.1030(b)) that they would be considered regulated waste.

      2. Contaminated equipment

        In the event that equipment becomes contaminated with blood or OPIM, the employee shall immediately contact a supervisor to review how to proceed in this situation. Gloves and/or other appropriate barriers shall be used if contaminated equipment must be handled or transported to the nearest Regional/Area Office or other OSHA facility. Prior to transport, a biohazard label is to be attached to any contaminated equipment and is to state which parts are or remain contaminated. If the biohazard label on the equipment is not visible through the bag (e.g. bag is not transparent), another biohazard label should be attached to the bag’s exterior.

        The equipment shall be examined at the nearest Regional/Area Office or other OSHA facility (e.g. Salt Lake Technical Center) prior to servicing or shipping and decontaminated (e.g. wiped with a bleach solution or other disinfectant, as determined by the Office Director) as necessary. The ARA for Enforcement Programs or the on-site Area Director will determine how and if the equipment can be decontaminated at the Office level. Contaminated items are not to be placed or stored in areas where food is kept, and decontamination should be accomplished as soon as possible following the inspection or incident where contamination occurred. Decontamination is not to take place in any area where food or drink is consumed. Cloths used to wipe contaminated equipment can be discarded as non-regulated refuse unless they somehow become contaminated to the extent that they would be considered regulated waste as defined in 29 CFR 1910.1030(b).

        The employee who is shipping equipment that remains contaminated shall notify the receiving servicing center or manufacturer that contaminated equipment is being sent so that the receiving facility can take proper precautions. In addition, this employee should contact the package delivery company regarding appropriate packaging of the item(s).

    2. Personal Protective Equipment

      Field personnel are expected to avoid contact with blood and OPIM as well as contact with surfaces and items contaminated with such materials. In the unlikely event that equipment becomes contaminated, OSHA will provide appropriate gloves of proper size (see Appendix B). Field personnel will carry these gloves on inspections. Gloves are to be replaced as soon as practical if they become contaminated or as soon as feasible if they are torn, punctured or whenever their ability to function as a barrier appears to be compromised. These gloves are not to be washed or decontaminated for reuse.

      Field personnel are to determine the extent of contamination of gloves prior to their removal. It is unlikely that gloves worn by field personnel would be contaminated to the extent that they would be considered regulated waste, but if this should occur, the gloves are to be discarded in a regulated waste container at the inspection site. In a facility not in compliance with 29 CFR 1910.1030 regarding regulated waste, see section 4.0.C.

      It is anticipated that field personnel will not need personal protective equipment (PPE) other than gloves. It is expected that field personnel will avoid situations in which any other PPE would be needed.

    3. Regulated Waste

      OSHA does not anticipate that the duties of OSHA employees will generate regulated waste.

    4. Post-exposure Evaluation and Follow-up

      OSHA shall provide post-exposure evaluation, follow-up and post-exposure prophylaxis, when medically indicated, to any employee who suffers an exposure incident while performing their work assignments. All medical evaluations and procedures are to be made available at no cost to OSHA personnel, at a reasonable time and place, and under the other conditions set forth in 29 CFR 1910.1030(f).

      1. Handling an Exposure Incident

        In the unlikely event of an exposure incident (as defined in 29 CFR 1910.1030(b)), the OSHA employee is to immediately, or as soon as feasible, wash the affected skin with soap and water and flush any affected mucous membranes with water. The employee should then seek medical attention. A bloodborne pathogens exposure incident is an event for which immediate attention must be sought because the effectiveness of post-exposure prophylaxis is dependent on prompt administration (i.e., within hours of the exposure incident). An employee who has had an exposure incident is to report the incident to his or her supervisor as soon as possible.

        The Area Director/Office Director or designee shall instruct the employee to seek medical attention from a healthcare provider capable of performing a post-exposure evaluation, and, if indicated, able to provide the hepatitis B vaccination series, baseline testing for hepatitis B and C and HIV, prophylaxis for hepatitis and HIV, and any future testing or prophylaxis as recommended by the U.S. Public Health Service. Ideally, this evaluation will be performed by a healthcare provider with whom an arrangement has been pre-established. If the employee is in the field and far from a pre-established healthcare provider, the supervisor shall instruct the employee to go to the nearest emergency room in the area. Another healthcare provider, such as an occupational medicine clinic, may be used if it can be determined that the provider is capable of giving the necessary evaluation, treatment and prophylaxis without undue delay. Not all healthcare providers are familiar with the U.S. Public Health Service Guidelines or keep hepatitis B vaccine, hepatitis B immune globulin (HBIG) or medications for HIV post-exposure prophylaxis onsite. Hospital emergency rooms are more likely than other healthcare providers to be capable of providing a post-exposure evaluation and are more likely to have Hepatitis B vaccine, Hepatitis B Immune globulin and HIV post-exposure prophylaxis medications readily available. Please note that the Federal Occupational Health centers do not offer post-exposure evaluation.

        The supervisor will inform the Area Director/Office Director or designee who will contact the facility where the exposure incident occurred. The area Director/Office Director or designee is to work together with the facility, with the assistance of the director of OOMN if needed, to ascertain the source individual, and communicate that information to the healthcare facility evaluating the OSHA employee. The Area Director must also contact the ARA-AP and the Regional Administrator to inform them of the incident.

        Following an exposure incident, an Exposure Incident Report (see Appendix A) will be completed by the OSHA employee in consultation with the supervisor without delay. The report is to be given by the employee to the evaluating healthcare provider. Report information will include (a) a description of the exposed employee’s duties as related to the exposure incident; and (b) documentation of route(s) of exposure and circumstances under which exposure occurred. (The supervisor may need to complete and send this form by facsimile to the evaluating healthcare facility if the employee does not have the form with him or her in the field. This will help to assure timely sharing of information and allows the employee to travel directly from the field to the healthcare facility, avoiding a delay in obtaining the post-exposure evaluation.

      2. Information Provided to the Evaluating Healthcare provider

        In accordance with 29 CFR 1910.1030, the supervisor will see that the health care facility that is performing the employee’s post-exposure evaluation is provided with a copy of 29 CFR 1910.1030 and the other materials for the Evaluating Healthcare Provider included in Appendix A of this program. These materials may be hand-carried by the employee and/or supervisor or sent by facsimile. Alternately, supervisors may require employees to carry these materials with them when they are in the field.

        The instructions for the healthcare provider describe the applicable requirements of 29 CFR 1910.1030(f) and instruct the healthcare provider to give a written opinion to the employee. The supervisor must obtain the written opinion from the employee when the employee returns to the duty station. The written opinion will be maintained at the employee’s assigned duty station.

        While at the evaluating healthcare facility, the employee should ask to sign a medical records release form requesting that the healthcare provider send a copy of the medical record of the evaluation to the OSHA’s Office of Occupational Medicine and Nursing. This medical documentation will become a part of the employee’s confidential employee medical record maintained in the Office of Occupational Medicine and Nursing.

    5. Communication of Hazard to Employees

      Labels and Bags

      OSHA will provide biohazard labels to be affixed to bags containing any contaminated equipment until they can be returned to an OSHA office or shipped to another facility. Biohazard labels are to be carried by all field personnel. OSHA will provide appropriate bags for containment of any regulated waste or contaminated equipment. Bags are to be carried by all field personnel. In addition, a bag and biohazard labels will be provided in any First-Aid kit. Bags will be disposed of as ordinary refuse except in the rare instance in which they are contaminated to the extent that they are considered regulated waste as defined by the standard. In such case, see Section 4.0.C. of this program.

    6. Recordkeeping: Post-Exposure Records

      1. Employee Medical Records

        Employee medical records are to be maintained by the Office of Occupational Medicine as part of the medical files of the CSHO Medical Examination Program. Such records are maintained in accordance with 29 CFR 1910.1020.

      2. Transfer of Records

        OSHA will comply with the requirements of 29 CFR 1910.1020(h) involving any transfer of records. Exposure incident records will remain at the office where the employee was assigned when the incident occurred, with a copy sent to the Office of Occupational Medicine. The employee may request and receive a copy of such records when transferring to another assignment.

  6. Procedures for Evaluating an Exposure Incident

    The Area Director, or a designee from the Area Office or the Office Director to whom the affected employee is assigned, will evaluate the circumstances surrounding any exposure incident. The evaluation should consist of at least:

    1. A review of the Exposure Incident Report completed by the OSHA employee;

    2. Documentation regarding a plan to reduce the likelihood of a future similar exposure incident; and

    3. Notification of the Office of Occupational Medicine and discussion of any similar incidents and planned precautions.

    Management will ensure that employee medical records and all other personally identifiable information is afforded all safeguards in accordance with the applicable provisions of DLMS-5 Chapter 200 “The Privacy Act of 1974 and Invasion of Privacy” and DLMS-9 Chapter 1200 Safeguarding Sensitive Data Including Personally identifiable Information.

    Such reports will be maintained at the employee’s assigned duty station, and copies are to be sent to the Office of Occupational Medicine and Nursing (OOMN) and to the Regional Administrator. OOMN will review these reports on a periodic basis so that this information can be considered when reviewing and updating this Plan.

  7. Responsibilities
    1. Offices

      Office directors will:

      1. Ensure that employees are trained and that training records are maintained in accordance with section III, paragraph A.4.5

      2. Determine how and if contaminated equipment can be decontaminated at the office level.

      3. Provide gloves and other supplies (e.g. bags) to field personnel.

      4. Arrange for appropriate disposal of regulated waste if an employee is unable to properly dispose of it on-site and therefore obligated to bring it back to the office for disposal.

      5. Instruct employees to obtain post-exposure evaluation and locate an appropriate healthcare facility for the evaluation in the event that an exposure incident occurs.

      6. Work with the employee to complete an exposure incident report in the event of an exposure incident.

      7. Ensure that the healthcare provider for any exposure incident is provided with a copy of 29 CFR 1910.1030 and the other materials in Appendix A of this Instruction.

      8. Obtain a written report completed by the healthcare provider who performs a post-exposure evaluation on an employee.

      9. Evaluate the Exposure Incident Report and other reports and send copies of these reports to OOMN and the Regional Administrator.

      10. Immediately notify the Regional Administrator, or designee, and the ARAAP of any exposure incident that occurs to an employee.

      11. Immediately notify the Regional Administrator when an employee reports that an on-site investigation could result in a potential exposure to blood or OPIM.

    2. Employees

      Employees will:

      1. Notify their supervisor immediately if they believe that an investigation could result in potential exposure to blood or OPIM, and wait for approval prior to entering any area where an exposure could occur.

      2. Not handle or touch contaminated objects.

      3. Take appropriate action if an occupational exposure occurs or if equipment becomes contaminated.

      4. Contact the supervisor immediately if an exposure incident occurs.

      5. Work with the supervisor as soon as possible, if an exposure incident occurs, to complete an Exposure Incident Report.

      6. Bring a copy of the healthcare provider's written report back to the supervisor after any post-exposure evaluation for an exposure incident.



This OSHA employee may have suffered an exposure incident as defined in the OSHA Bloodborne Pathogens standard and has presented to your facility for a post-exposure evaluation in accordance with the standard. To assist you in this evaluation, the employee and/or his/her supervisor should provide:

  1. A copy of OSHA standard 29 CFR 1910.1030, Bloodborne Pathogens;

  2. A description of the exposed employee's duties as they relate to the exposure incident;

  3. Documentation of the routes of exposure and circumstances under which it occurred;

  4. Results of the source individual's blood testing, if available; and

  5. All medical records relevant to this employee's appropriate treatment, including vaccination status.

After completing this evaluation, please:

  1. Inform the employee regarding the results of the evaluation and any follow-up evaluations or treatments needed;

  2. Complete the attached written opinion form and give it to the employee. (This form will be maintained in the office to which the employee is assigned); and

  3. Send a copy of all results and medical records from this evaluation to:

    U.S. Department of Labor – OSHA
    Office of Occupational Medicine, Room N3653
    200 Constitution Avenue, NW, Washington, DC 20210

    These copies will be maintained as part of the employee’s confidential medical record in OSHA’s Office of Occupational Medicine.

Should you have any questions regarding the evaluations or medical records, please contact the Director of OSHA’s Office of Occupational Medicine at (202) 693-2323.

A copy of 29 CFR 1910.1030 can be found at 56 Fed. Reg. 64175-64182 (Dec.6, 1991), or online at http://www.osha.gov/, and copied or printed out by OSHA to provide to the evaluating healthcare provider.


(Routes and Circumstances of Exposure Incident)

Please Print

Employee's Name_______________________________________Date___________________

Date of Birth___________________________

Telephone (Business)_________________________ (Home)____________________________

Job Title______________________________________________________________________

Date of Exposure_________________________Time of Exposure_________AM_________PM

Hepatitis B Vaccination Status_____________________________________________________

Location of Incident_____________________________________________________________

Describe the job duties you were performing when the exposure incident occurred





To what body fluid(s) were you exposed? _____________________________________________



What was the route of exposure (e.g. mucosal contact, contact with non-intact skin, percutaneous)?_______________________________________________________________________________



Describe any personal protective equipment (PPE) in use at the time of the exposure incident




Did PPE fail?_____________If yes, how?______________________________________________



Identification of source individual(s) (names) [Unless infeasible or prohibited by state or local laws]



Other pertinent information__________________________________________________________



Healthcare Provider's Written Opinion for Post-Exposure Evaluation


To the Evaluating Healthcare Provider:


After your evaluation of this OSHA employee, please assure that the following information has been furnished to the employee. Please initial beside the statements.


____________ The employee has been informed of the results of this evaluation.

____________ The employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation and treatment.

No other findings are to be included in this report


Please return this sheet to this employee ___________________________________________________

(Name of Employee)


Thank you for evaluating this employee:



(Healthcare Provider's Signature)



(Printed Name of Healthcare Provider)






Field Personnel should have the following materials to carry on inspections:

  1. At least 2 bags (appropriate for containment of any regulated waste that cannot be disposed of on site or for contaminated equipment)

  2. Non-sterile medical examination gloves, cleared by the Food and Drug Administration- of appropriate size (at least 2 pairs). (Non-latex gloves will be supplied to employees with latex allergies).

  3. Antiseptic towelettes.

  4. Disposable Shoe Covers