Everyone in our facility recognizes that even with good adherence to all of our exposure prevention practices, exposure incidents can occur.  As a result, we have implemented a Hepatitis B Vaccination Program, as well as set-up procedures for post-exposure evaluation and follow-up should exposure to bloodborne pathogens occur.


To protect our employees as much as possible from the possibility of Hepatitis B infection, our facility has implemented a vaccination program.  This program is available at no cost, to all employees who have occupational exposure to bloodborne pathogens.

The vaccination program consists of three (3) inoculations over a six (6) month period.   As part of their bloodborne pathogens training, our employees have received information regarding Hepatitis vaccination, including its safety and effectiveness.

The EHRS Department is responsible for overseeing our vaccination program.

Vaccinations are performed under the supervision of a licensed physician or other licensed health care professional.

To ensure that all employees are aware of our vaccination program, it is discussed in our bloodborne pathogens training.

All exposed employees who want the vaccinations should complete the Consent to Vaccinate Form. Training will be completed before vaccinations are received. Vaccinations will be provided at a nearby medical facility during working hours and at no cost to the employee. Vaccinations will be made available within 10 working days of an initial work assignment where there is an occupational exposure, unless the employee has previously received their complete hepatitis B series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.

Employees who decline to accept Hepatitis B vaccination must sign the Declination Form at the bottom of the Consent to Vaccinate form. However, if an employee later decides to accept the vaccination, it will be made available to the employee at that time, at no cost.

If a routine booster dose(s) of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, booster dose(s) will also be made available at no cost.

Documentation of refusal of the vaccination is maintained in the EHRS Department.


If one of our employees is involved in an incident where exposure to bloodborne pathogens may have occurred, there are two (2) things that we immediately focus our efforts on:

Immediate Treatment:

Reporting and Treatment Procedure:  See Accident Reporting in the Safety Manual for more information.

The Safety Committee investigates exposure incidents that occur in our facility.  This investigation involves gathering the following information:

After this information is gathered, it is evaluated, then the incident and its causes, is documented in the Safety Committee minutes.  Recommendations are made for avoiding similar incidents in the future. 

OSHA Recordkeeping - An exposure incident is evaluated to determine if the case meets OSHA's Recordkeeping requirements.  This determination and the recording activities are done by the Department of Environmental Health and Radiation Safety. 

In order to make sure that our employees receive the best and most timely treatment if an exposure to bloodborne pathogens should occur, our facility has set up a comprehensive post-exposure evaluation and follow-up process.  This process is overseen by the following departments:

  1. Human Resources Department
  2. Environmental Health and Radiation Safety Department

We recognize that much of the information involved in this process must remain confidential, and we will do everything possible to protect the privacy of the people involved.

Employees are transported to a nearby medical facility for post-exposure evaluation and follow-up.

As the first step in this process, the consulting health care professional will provide an exposed employee with the following confidential information:

Identification of the source individual, if applicable. (unless infeasible or prohibited by law)

Next, if possible, the source individual's blood is tested to determine HBV or HIV infectivity.  This information will also be made available to the exposed employee, if it is obtained.  At that time, the employee will be made aware of any applicable laws and regulations concerning the disclosure of the identity and infectious status of the source individual.

Finally, the blood of the exposed employee is collected and tested for HBV and HIV status as soon as feasible after the exposure incident (an employee may decline this step).

Once these procedures have been completed, the healthcare professional will discuss the exposed employee's medical status with him/her.  This includes an evaluation of any reported illnesses, as well as any recommended treatment.

When applicable, percutaneous injuries from contaminated sharps will be recorded and maintained in the Department of Environmental Health & Radiation Safety. Each incident will include at least:

If a copy is requested by anyone, it must have any personal identifiers removed from the report.


To assist the healthcare professional we will forward any documents that are requested, including the following:


After the consultation, the physician or health care professional provides our facility with a written opinion evaluating the exposed employee's situation.  In keeping with this process, emphasis on confidentiality, the written opinion will contain only the following information:

All other findings or diagnosis will remain confidential and will not be included in the written report.


The Consulting Health Care Professional and the Human Resources Department maintain medical records on our employees. 

Medical records are maintained for each employee with occupational exposure in accordance with 29CFR 1910.1020 "Access to Employee Exposure and Medical Records". These confidential records are kept for at least the duration of employment plus 30 years.

Exposure Incident Evaluation Records: Once an exposure incident has been evaluated, and any modifications or corrective actions put into place, the exposure incident evaluation records are maintained in the Department of Environmental Health & Radiation Safety.

University of the Sciences in Philadelphia • 600 South Forty-third Street • Philadelphia, PA 19104-4495 • phone: 215-596-8800 • email: safety@usp.edu