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SOP-261EMSSOP

Bloodborne Pathogens

Exposure prevention, PPE, post-exposure procedures.

Read before using

This is a template. It is not your department's policy.

Tailboard templates are drafted as generic starting points aligned to national standards. They are nota substitute for your department's own review or for adoption through your Authority Having Jurisdiction (AHJ). For topics carrying significant exposure (use of force, medical scope, civil rights), route through qualified counsel before adoption.

Every placeholder marked [BRACKETED] must be completed before adoption. Every section must be reviewed against your department's staffing, apparatus, water supply, EMS scope, geography, and the specific laws of your state. What applies to a career department in a city may not apply to a volunteer department in a rural jurisdiction, and vice versa.

Standards, regulations, and best practices are updated regularly. Verify the current edition of every standard cited before adopting this document. Once adopted, this document becomes your department's responsibility — not Tailboard's.

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Open it in the Policy Builder. Answer a few questions about your staffing, apparatus, and conditions — we'll adapt every section to match.

Number

SOP-261

Version

1.0

Last reviewed

2026-01-01

Next review

2027-01-01

Summary

This SOP implements OSHA 29 CFR 1910.1030 for [DEPARTMENT NAME]. It establishes the written exposure control plan, PPE requirements, post-exposure medical follow-up, and record-keeping. Bloodborne pathogen compliance is mandatory federal law and is frequently audited.

Definitions

OPIM
Other Potentially Infectious Materials. Any body fluid other than blood that carries potential pathogen risk.
Exposure Incident
A specific eye, mouth, mucous-membrane, non-intact skin, or parenteral contact with blood or OPIM.
Universal / Standard Precautions
Treating all blood and body fluids as if known to be infectious, regardless of patient history.
Designated Officer
The member responsible under the Ryan White Act for receiving exposure notifications from treating hospitals.

Purpose

To protect members from occupational exposure to bloodborne pathogens, comply with OSHA 29 CFR 1910.1030, and ensure prompt medical follow-up when exposure occurs.

Scope

Applies to every member who may have occupational exposure to blood or OPIM in the course of department duties, including firefighting, EMS, and technical rescue.

Standard Precautions

Every patient contact is treated as potentially infectious. PPE is selected based on the anticipated exposure, not the perceived risk of the patient.

  • Gloves for every patient contact.
  • Eye protection and mask for airway procedures, bleeding, or any activity where splash is possible.
  • Gown for significant bleeding, childbirth, or extensive contact.
  • Pocket mask / BVM with filter for ventilation.

Engineering Controls

  • Sharps containers on every EMS-equipped apparatus.
  • Closed IV catheter systems and needleless devices when available.
  • Biohazard bags for contaminated materials.
  • Hand-hygiene products (hand sanitizer + soap and water) accessible on every rig.

Work Practice Controls

  • Never recap needles by hand.
  • Immediately dispose of sharps in the sharps container.
  • Wash hands immediately after removing gloves.
  • No eating, drinking, smoking, or applying cosmetics where occupational exposure is possible.

Hepatitis B Vaccination

  • HBV vaccine is offered at no cost to every member with occupational exposure, within 10 working days of assignment to a covered role.
  • Members who decline sign the OSHA-specified declination form.
  • A member who declines may request and receive vaccination at any later time.
  • Titers and boosters are provided per CDC recommendations.

Post-Exposure Procedure

  1. If exposure occurs: immediately wash the exposed area with soap and water; flush mucous membranes with water.
  2. Notify your officer.
  3. Report to the designated medical provider (hospital ED or occupational health) within 2 hours.
  4. Complete the [DEPARTMENT] exposure report form.
  5. Source identification, source testing, and baseline testing of the exposed member are coordinated by the medical provider.
  6. Post-exposure prophylaxis (PEP) is evaluated per CDC guidelines.
  7. Medical follow-up continues per CDC schedule.

Ryan White Act — Designated Officer

[DEPARTMENT NAME]'s Designated Officer under the Ryan White Act is [NAME, TITLE]. Hospitals that admit a patient later confirmed to have certain infectious diseases are required to notify the Designated Officer if emergency responders may have been exposed. The Designated Officer promptly notifies the exposed members.

Record-Keeping

  • Medical records related to occupational exposure are kept confidentially and separately from general personnel files.
  • Records are retained for the duration of employment plus 30 years.
  • Training records are retained for 3 years minimum.

Responsibilities

Chief / Health & Safety Officer

  • Maintain the written exposure control plan; review annually.
  • Provide HBV vaccination, PPE, engineering and work-practice controls.
  • Arrange post-exposure medical evaluation.
  • Serve as or designate the Designated Officer.

Members

  • Use standard precautions on every patient contact.
  • Report exposures immediately.
  • Comply with post-exposure medical follow-up.

Training Requirements

  • Initial training at onboarding, before assignment to any role with occupational exposure.
  • Annual refresher training for every covered member.
  • Training covers: the exposure control plan, PPE, work practice controls, post-exposure procedures, HBV vaccine, and hazard communication.
  • Training is documented per OSHA 1910.1030.

References

  • 29 CFR 1910.1030OSHA Bloodborne Pathogens Standard
  • Ryan White CARE Act42 U.S.C. § 300ff — emergency responder notification
  • CDC GuidelinesUpdated U.S. Public Health Service Guidelines for Post-Exposure Prophylaxis
  • NFPA 1581Standard on Fire Department Infection Control Program

Adapt this template

Before this template becomes your department's policy, review the following items and adjust accordingly. Anything else that does not match your operation should be updated as well.

  • Designate your Designated Officer by name and title.
  • Name your contracted occupational-health provider.
  • Reference your Bloodborne Pathogens training schedule.
  • Attach your department's exposure report form.

Adoption signature

Adopted by (Name, Rank)
Signature
Effective date
Next scheduled review

Before adoption checklist

  • ☐Replace [DEPARTMENT NAME] throughout the document.
  • ☐Complete every [BRACKETED] placeholder.
  • ☐Confirm the current edition of every cited standard.
  • ☐Check against your state statutes and state fire marshal rules.
  • ☐Route for chief review. Topics with significant exposure (use of force, medical scope) also go through qualified counsel.
  • ☐Confirm alignment with any mutual-aid agreements.
  • ☐Schedule a training plan for the new policy before effective date.
  • ☐Announce adoption in writing to all members. Archive the prior version.
  • ☐Set the next review date — annually at minimum.