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River East Transcona School Division
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Biological Substance Exposure Assessment and Control (Bloodborne Pathogen Precautions)

 Safe Operating Procedure



To establish divisional expectations and standards regarding  biological substance (blood, bodily fluids, other) program at River East Transcona School Division (RETSD) that meets or exceeds all municipal, federal and provincial legislated workplace safety and health program requirements.


A biological substance control program must be defined and documented for compliance as part of Element 6, develop a plan to control chemical and biological hazards, for the effective development and implementation of a workplace safety and health program under Manitoba legislation.




This safe operating procedure and associated documents establish a procedure for a biological substance control program for all workers at RETSD.


The best practices apply to all RETSD worksites.






RETSD management is responsible for assessing risk and managing a biological substance assessment and control program at all facilities.




All biological substance exposure assessment and control processes at RETSD is defined and controlled under a number of programs, including, but not limited to, the following:


  • Biological Substance Exposure Assessment and Control

  • Chemical Substance Exposure Assessment and Control Program

  • WHMIS Program

  • Hazardous Waste Management          

  • Science Laboratory Safety

  • Job Hazard Analysis and Safe Work Instructions (Risk Assessment General Provisions)

  • Caring for Students

  • Personal Protective Equipment

  • Other


People Authorized to Handle Biological Substances


Only trained and authorized personnel may handle and dispose of biological substances that pose a risk to worker safety and health.


People Authorized to Handle Blood and Bodily Fluids


Personnel trained in First Aid shall administer first aid at RETSD. First Aiders are trained in Bloodbourne Pathogens Precautions (i.e. universal precautions) and therefore are considered leaders in managing and directing any post incident clean up required to eliminate the hazards associated with blood and / or bodily fluids (B/BF) exposure in the workplace.


Maintenance staff (custodians) are trained in biological substance exposure control and are authorized to handle the cleanup and disposal of biological substances.


Blood and Bodily Fluids Exposure Control


When there is a risk of significant exposure to B/BF in the workplace, all workers must avoid contact with the pathogen and report the situation to a First Aider or Custodian. The First Aider or Custodian shall determine the appropriate response and lead, direct or conduct the safe work practices to address the situation.


All employees are expected to take necessary steps to prevent B/BF exposure in the workplace, including seeking appropriate first aid if they are injured and secreting B/BF, and to implement safe work practices under the direction and supervision of a qualified First Aider or Custodian when assisting in cleanup activities, when required.


Biological Substance Identified Risks


Health and safety authorities throughout the world agree that blood and certain other body fluids (B/BF) should be considered a hazard for the potential of bloodbourne pathogen infection in directly exposed workers. "Bloodbourne Pathogen Precautions" (formerly Universal Precautions) is the standard practice for preventing exposure to B/BF.


There are a number of bloodbourne pathogens of which Hepatitis B and C and HIV (AIDS) are the most important. Transmission occurs by direct contact with infected blood or certain other body fluids (e.g. semen, vaginal secretions, blood tinged body cavity fluids, etc.). Exposure to feces, urine, vomitus, sputum, tears, nasal secretions are not considered risky unless visibly blood tinged. For workplaces where workers are exposed to sharp objects (e.g. knives, saws, scissors, and needles), procedures for safe handling and first aid are required.


What is a significant exposure?


Significant exposure to blood or body fluids where there is risk of infection happens only in certain ways:


  • puncturing the skin with a sharp object coated with B/BF e.g. needle stick, razor, broken glass, scissors, knife, etc.;

  • splashing blood onto mucous membrane (eyes, nose, mouth);

  • splashing blood onto non-intact skin (e.g. abrasion, eczema, other damaged skin).


Safe Work Practices For Managing Exposure to Human Blood/Bodily Fluids


If an exposure incident occurs.


1. Determine whether a significant exposure has occurred (see definition).

2. Get first aid immediately - flush thoroughly.

3. Report the incident to appropriate supervisors as per IVT standard incident reporting procedures

4. Seek medical attention immediately if a significant exposure occurred - preferably within 2 hours. Timely assessment is necessary for the initiation of preventative medication and/or vaccination. (Reference: the Manitoba Health "Integrated Post Exposure Protocol")


Note: B/BF contact with intact skin is not considered to be a risk for the spread of bloodbourne pathogens.


Personal Protection


Hand Washing


Hand washing is the most important aspect of infection control, regardless of the appropriate use of gloves. Hands must be washed thoroughly with soap and water after all direct contact with B/BF.


Hand Barrier Protection


Latex or vinyl gloves are to be worn:


  • when handling any items soiled with B/BF;

  • when there is direct contact with B/BF;

  • when in contact with open wounds or sores.


Respiratory Protection


Disposable devices with a one-way valve mechanism should be available for mouth to mouth cardiopulmonary resuscitation (CPR). All First Aiders should have easy access to this device at all times.


Workplace Clean-Up Procedures




Floor areas or benches, which have been contaminated with B/BF, should be promptly cleaned with absorbent disposable paper toweling which is then disposed into plastic bags. The area should then be cleaned with water and detergent followed by disinfecting with approved disinfectant and allowed to air-dry. If mops have been used in the cleanup, they should be thoroughly washed in soap and water and dried before re-use.


Soiled Clothing


Clothing soiled with B/BF should be removed and laundered in the usual fashion.


Soiled Tools and Instruments


Tools, chisels, drill bits, etc. which come into contact with B/BF should be cleaned with paper towels, washed and decontaminated with an appropriate disinfectant.


Cleaning Products


Soap (and water) is the most common and most easily accessible cleaning product.




Maintenance Department stocks approved disinfectant products for use at RETSD facilities. For decontamination of aluminum or electronic equipment, use 70% isopropyl alcohol solution applied for 10 minutes.


Sharps and Contaminated Cleaning Materials Disposal Procedures


  • Safe pickup procedures to be practiced.

  • Do not place in regular indoor garbage bins, dispose of directly in large refuse bins outside, sharps container and all.

  • Safe garbage handling procedures to be used.


For more information, visit the Manitoba Health web site for more information.




A combination of hard-copy postings, distributions and electronic posting will be used to communicate safety and health program information within RETSD.




All stakeholders shall be trained to their required level of involvement in the WSHMS to become familiar with its structure, organization, and how to look up and access information both electronically and in hard copy form through:


  • New employee orientation, employee manuals or employment information packages


  • Return to work or remedial programs, as required on an individual basis


  • Planned ongoing training through team meetings, individual coaching or other methods as developed or adopted




Ultimately, the superintendent shall be responsible for the sustainability of the WSHMS, and shall enforce compliance to standards at a divisional level.


Workplace safety and health management system compliance shall be managed through the application of performance management and progressive discipline policies and procedures.


Worker failure to comply with provisions of the RETSD safety program may lead to discipline, up to and including discharge from employment and / or other remedies available at law.



 Document Number



 Document Control


Divisional Safety and Health Officer


Divisional Safety and Health Officer


Divisional Workplace Safety and Health Committee


Director of Human Resources


Director of Maintenance

Origin Date:

August 31, 2010

Last Revised:

August 8, 2018

Last Reviewed:

August 8, 2018

Next Review On or Before:

August 8, 2021




Manitoba Workplace Safety and Health Act or equivalent legislation as applicable


Manitoba Workplace Safety and Health Regulation or equivalent legislation as applicable


Manitoba Workplace Safety and Health Regulation Part 36 – Chemical and Biological Substances


Manitoba Workplace Safety and Health Regulation Part 39 – Health Care Facilities


Manitoba Workplace Safety and Health Program Element 02 – Identifying and Controlling Hazards


All other associated and applicable workplace safety and health management system documents