5411 - Comprehensive HIV and Bloodborne Pathogens Policy for Schools K-12

Policy 5411 Comprehensive HIV and Bloodborne Pathogens Policy for Schools K-12 title box

The Human Immunodeficiency Virus (HIV) is not transmitted through casual contact and, therefore, is not reason in itself to treat individuals having or perceived as having HIV differently from other members of the school community. Accordingly, with respect to HIV disease, including acquired immune deficiency syndrome (AIDS), the Southwest Vermont Supervisory Union, Bennington School District, Inc., Mount Anthony Union School District, North Bennington Graded School District, Pownal School District, Shaftsbury School District, and Woodford School District recognize:
  • the rights of students and employees with HIV,
  • the importance of maintaining confidentiality regarding the medical condition ofany individual,
  • the importance of an educational environment free of significant risks to health, and
  • the necessity for HIV education and training for the school community and the community-at-large.

A. General Provisions:

  1. The school district shall not discriminate against or tolerate discrimination against any individual who has or is perceived as having HIV.
  2. A student who has or is perceived as having HIV is entitled to maintain his/her attendance in current educational setting, unless otherwise provided by law, and shall be afforded opportunities on an equal basis with all students.
  3. No applicant shall be denied employment and no employee shall be prevented from continued employment on the basis of having or being perceived as having HIV. Such an employee is entitled to the rights, privileges, and services accorded to employees generally, including benefits provided school employees with long-term diseases or disabling conditions.

B. Confidentiality, Disclosure, and Testing:

  1. A student or student's parent/guardian, or an applicant/employee, may, but is not required to, report HIV status to any school personnel.
  2. Except as otherwise permitted by law, no school personnel including school board members and volunteers, shall disclose any HIV-related information, as it relates to prospective or current school personnel or students, to anyone except in accordance with the terms of a written consent. The superintendent shall develop a written consent form (see Appendix A) which details the information the signatory permits to be disclosed, to whom it may be disclosed, its specified time limitation, and the specific purpose for the disclosure. The school district shall not discriminate against any individual who does not provide written consent.
  3. No school official shall require any applicant, employee, or prospective or current student to have any HIV-related test.

C. Education and Instruction:

  1. HIV is not, in itself, a disabling condition, but it may result in conditions that are disabling. To the extent that a student who has HIV is determined to meet the criteria for eligibility for accommodations under state and federal non-discrimination laws or for special education services, the school district shall meet all procedural and substantive requirements.
  2. The school district shall provide systematic and extensive elementary and secondary comprehensive health education which includes education on HIV infection, other sexually transmitted diseases as well as other communicable diseases, and the prevention of disease, as required by state law.

D. Exposure to Bloodborne Pathogens and Universal Precautions:

  1. The school district shall comply with applicable Vermont Occupational Safety and Health Administration (VOSHA) rules in order to protect employees who are reasonably anticipated to be exposed to bloodborne pathogens as part of their regular job duties.
  2. In the event that the school nurse determines that a student has had a significant exposure to blood (as defined in the district's VOSHA Exposure Plan), the parent(s)/guardian(s) will be notified immediately and advised to consult the child's physician at once.
  3. The superintendent or his/her designee shall determine those employees (by job class and possibly by task or procedure) who are reasonably anticipated to have occupational exposure to blood or other potentially infectious materials as part of their duties. These employees will be protected in strict accordance with the positions of the Bloodborne Pathogens Standard.
  4. Students and all staff not covered by the Bloodborne Pathogens Standard shall be instructed to avoid contact with potentially infectious materials and blood and shall immediately contact a member of the staff who is covered by the exposure control plan. When this is not possible, any person providing assistance shall follow universal precautions.
  5. Universal Precautions shall be posted in key area(s) in each school.

E. Enforcement:

  1. A person who violates this policy may be subject to remedial and/or disciplinary action in accordance with applicable laws, collective bargaining agreements, policies, and/or disciplinary codes.

Legal References:

1 V.S.A. §317(b)(7) and (11)
Section 504 of the Rehabilitation Act of 1973
18 V.S.A. §1127
Individuals with Disabilities Education Act (IDEA)
Title VI, Civil Rights Act of 1964, and as amended by the Equal Employment Act of 1972
American with Disabilities Act, P.L. 101-335 (1990)
16 V.S.A. §131 et seq., §906
Occupational Safety and Health Act of 1970
Occupational Exposure to Bloodborne Pathogens Standard (29 C.F.R. §1910.1030)
21 V.S.A. §201(c)(2) and §224.

Policy 5411 warning and adoption dates



To maintain an atmosphere of trust with staff members, students, families, and the community, a policy that encourages confidentiality is essential. It is important that people who have the Human Immunodeficiency Virus (HIV) and their families feel certain that their names will not be released against their wishes to others without a need to know. A policy on confidentiality that is strictly enforced will also provide protection to the school district from legal action and from potentially adverse reactions that might result.

To promote confidentiality and to avoid the violation of state and federal laws that protect the confidentiality of medical records, the following procedures are suggested:
  1. All medical information in any way relating to the HIV status of any member of the school community, including written documentation of discussions, telephone conversations, proceedings, and meetings shall be kept in a locked file. Access to this file shall be granted only to those persons identified in writing by the student or student's parent/guardian, or the employee, as having a direct need to know. Filing and photocopying of related documents may be performed only by persons named in the written consent.
  2. No record referring to HIV status medical information shall ever be faxed.
  3. Medically-related documents that are to be mailed shall be marked "Confidential." Names of persons mailing documents and those receiving the documents shall be identified on the written consent form by the student or student's parent/guardian, or the applicant/employee.
  4. A written consent form shall be completed prior to each disclosure and release of HIV-related information. (Sample attached.)
  5. Each disclosure made shall be noted in the student or employee's personal file. The list of such disclosures shall be made available to student, parent/guardian, or employee upon request.
  6. Schools shall comply with Vermont Occupational Safety and Health Administration (VOSHA) rule §1910.20 which concerns maintenance of and access to employee medical records. [Note: §1910.20 is incorporated by reference into §1910.1030 (h).]

Exposure Control Plan

The Southwest Vermont Supervisory Union (SVSU) is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this goal, the following Exposure Control Plan (ECP) is provided to eliminate or minimize occupational exposure to blood borne pathogens in accordance with OSHA standard 28 CFT 1910.1030, “Occupational Exposure to Blood borne Pathogens.”

The ECP is a key document to assist our schools in implementing and ensuring compliance with standard, thereby protecting our employees.

This ECP includes:
  • Policy Administration
  • Determination of employee exposure
  • Implementation of various methods of exposure control, including:
    • Universal precautions,
    • Exposure and work practice controls,
    • Personal protective equipment (PPE)
    • Housekeeping
  • Hepatitis B Vaccination
  • Post-exposure evaluation and follow-up
  • Communication of hazards to employees and training
  • Recordkeeping
  • Procedures for evaluating circumstances surrounding exposure incidents
Implementation methods for these elements of the policy and standard are discussed in the subsequent pages of this Exposure Control Plan.


  • The SVSU is responsible for implementation of the ECP. The superintendent, or his/her designee will maintain, review, and update the ECP at least annually with input from the school nurses of the SVSU, and whenever necessary to include new or modified tasks and procedures.
  • Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP.
  • The principal will ensure that the school will provide and maintain all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. The principals will also ensure that adequate supplies of the equipment are available in the appropriate sizes.
  • The Principal will be responsible for ensuring that all medical actions required by the standard are performed and the appropriate employee health and OSHA records are maintained.
  • The School Principal will be responsible for training, documentation of training, and making the written ECP available to employees.


All employees in the school system are at some risk of exposure and shall be required to complete the blood borne pathogen GCN training as part of their school year, and/or new hire orientation provided by the SVSU.

The following is a list of job classifications in our schools in which all employees have greater occupational exposure:
  • Custodian
  • Maintenance
  • Nurse
  • Special education staff (with exposure risk)
The Occupational Safety and Health Administration (OSHA) also states that teachers and paraprofessionals in schools where instruction is provided for the developmentally disabled are at an increased risk of contracting a blood borne pathogen due to children’s vulnerability to injury, special medical needs, and dependence on adults for personal care (OSHA, 1996).

The exposure determination of school employees is the responsibility of the school or district administrator. However, school administrators may seek the assistance of the school nurse or the local health department concerning the determination of risk exposure for school personnel. All staff may be at some risk and need to follow universal precaution guidelines and protocols.

Part-time, temporary, contract and per diem or substitute employees for those job classifications listed above are covered by the Comprehensive HIV and Blood Borne Pathogens Policy #5411. In service training on this policy will be provided during the orientation program for these employees. The school Administrator will ensure that the policy is followed for this type of employee.


Universal Precautions

All employees will utilize universal precautions. Universal precautions is an approach to infection control to treat all human blood and certain human body fluids as if they were known to be infectious for HIV, HBV and other bloodborne pathogens, (Bloodborne Pathogens Standard 29 CFR 1920.1030(b) definitions).

Bloodborne pathogen standard 29 CFR 1910.1030(d) (1) requires:
  • Employees to observe Universal Precautions to prevent contact with blood or other potentially infectious materials (OPIM).
  • Under Circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials.
  • Treat all blood and other potentially infectious materials with appropriate precautions such as:
    • Use gloves, masks, and gowns if blood or OPIM.

Exposure Control Plan

Employees covered by the blood borne pathogens standard and policy receive an explanation of this ECP during their annual and/or initial training session. All employees can review this plan at any time during their work shifts by contacting the administrator of their building.

The Superintendent, or his/her designee, is responsible for reviewing, maintaining and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures that affect occupational exposure and to update new or revised employee positions with occupational exposure. Records are maintained for all employees, including substitutes, covered under this plan. Human Resources will ensure that all employees including substitutes are informed of the policy and protocols.

Exposure Controls and Work Practices

Exposure controls and work practices will be used to prevent or minimize exposure to blood borne pathogens.

Specific safety techniques and work practice controls used are listed below:
  • Latex fee exam gloves
  • Protective gowns
  • Masks
  • Utility gloves
  • Sharps disposal container
  • Specialized cleaning practices/products
  • Eye protection
Sharps disposal containers are inspected and maintained or replaced by the school nurse whenever necessary to prevent overfilling.

The school identifies the need for changes in exposure controls and work practices through post-exposure evaluation and input from the nursing and administrative teams.

The nursing team and maintenance/custodial staff will evaluate new procedures and new products regularly by literature review, supplier information and recommendation of the Vermont Department of Health.

The Principal of the school is responsible for ensuring that these recommendations are implemented.

Personal Protective Equipment (PPE)

PPE is provided to our employees at no cost to them. Training in the use of the appropriate PPE for specific tasks or procedures is provided by SVSU in annual training (GCN) and reinforced by the nursing staff at each school building.

The types of PPE available to employees are gloves, eye protection, masks and cleaning supplies. PPE is located in the nurses’ office and in designated areas and may be obtained through the school nurse or maintenance/custodial department. All employees using PPE must observe the following protective protocols.

Protocol: Using Personal Protective Equipment

  • Wash hands immediately or as soon as feasible after removing gloves or other PPE.
  • Remove PPE after it becomes contaminated and before leaving the work area.
  • Used PPE may be disposed of in the regular trash unless saturated with blood. PPE must be disposed of in a red bag if completely saturated with blood.
  • Wear appropriate gloves when it is reasonably anticipated that there may be hand contact with blood or OPIM, and when handling or toughing contaminated items or surfaces; replace gloves if torn, punctured or contaminated, or if their ability to function as a barrier is compromised.
  • Utility gloves may be decontaminated for reuse of their integrity is not compromised; discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration.
  • Never wash or decontaminate disposable gloves for reuse.
  • Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to the eye, nose, or mouth.
  • Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with the outer surface.

Protocol for Custodial/Maintenance:

Waste/Sharps Disposal

Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see the following section “Labels”), and closed prior to removal to prevent spillage or protrusion of contents during handling.

Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leak proof on sides and bottoms, and appropriately labeled or color-coded. Sharps disposal containers are available in the school nurse office.

Bins and pails (e.g., wash or emesis basins) are cleaned and decontaminated as soon as feasible after visible contamination.
Broken glassware that may be contaminated is only picked up using mechanical means, such as a brush and dustpan.

The procedure for handling sharps disposal containers is: 

Protocol for Laundry:

The following laundering requirements must be met:
  • Handle contaminated laundry as little as possible, with minimal agitation.
  • Place wet contaminated laundry in leak-proof, labeled or color-coded containers before transport. Use red bags or bags marked with biohazard symbol (specify either red bags or bags marked with biohazard symbol) for this purpose.
  • Wear the following PPE when handling and/or sorting contaminated laundry:
    • Gloves
    • Gowns
    • Eye protection
    • Mask


Nurses and the maintenance/custodial department of the school are responsible for ensuring that warning labels are affixed or red bags are used as required if regulated waste or contaminated equipment is brought into the facility. Employees are to notify the maintenance/custodial department if they discover regulated waste containers, contaminated equipment, etc., without proper labels.

The hepatitis B vaccination series is available at no cost after initial employee training and within 10 days of initial assignment to all employees identified in the exposure determination section of this plan.
Vaccination is encouraged unless:
  1. Documentation exists that the employee has previously received the series;
  2. Antibody testing reveals that the employee is immune; or
  3. Medical evaluation shows that vaccination is contraindicated. Human Resources will be responsible to collect this information and maintain documentation.
However, if any employee declines the vaccination, the employee must sign a refusal form (See Appendix A of this plan). Employees who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the vaccination is kept at the Human Resources Office.

Vaccination will be provided by the Occupational Health department at Southwestern Vermont Health Care or the staff member’s primary care physician.

Following the medical evaluation, a copy of the health care professional’s written opinion will be obtained and provided to the employee within 15 days of the completion of the evaluation. It will be limited to whether the employee requires the hepatitis vaccine and whether the vaccine was administered.


Should an exposure incident occur, contact the school nurse in your building.

Following initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed:
  • Document the routes of exposure and how the exposure occurred on an incident report. Report will be forwarded to Human Resources.
  • Identify and document the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law).
An immediately available confidential medical evaluation and follow-up will be conducted by the Emergency Department at SVMC.


Health care professional(s) responsible for employee’s hepatitis B vaccination and post-exposure evaluation and follow-up are trained in OSHA’s blood borne pathogens standard.

Human Resources ensures that the health care professional evaluating an employee after an exposure incident receives the following:
  • A description of the employee’s job duties relevant to the exposure incident
  • Route(s) of exposure
  • Circumstances of exposure
  • If possible, results of the source individual’s blood test
  • Relevant employee medical records, including vaccination status
Health Care Professional provides the employee with a copy of the evaluating health care professional’s written opinion within 15 days after completion of the evaluation.


The Principal and the school nurse will review the circumstances of all exposure incidents to determine:
  • Exposure controls in use at the time
  • Work practices followed
  • A description of the device being used (including type and brand)
  • Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.)
  • Location of the incident
  • Activity being performed when the incident occurred
  • Employee’s training
The School Nurse will record all percutaneous injuries from contaminated sharps in a “Sharps Injury Log”.

Employee Training

All employees who have possible occupational exposure to blood borne pathogens receive initial and annual training conducted by SVSU preferred annual online training provider (E.g. GCN training). Each school Principal and nurse will also offer training with the staff on individual school safety procedures and location of supplies.

All employees (custodians, maintenance, special educators with high risk of exposure, others who have hazardous occupational exposure to blood borne pathogens receive training on the epidemiology, symptoms, and transmission of blood borne pathogen diseases. Training will be provided in individual schools by the school nurse. The head of maintenance will train the maintenance/custodial staff. Materials for this training are available through the SVSU. The training program covers, at a minimum, the following elements:
  • A copy of SVSU comprehensive HIV and Bloodborne Pathogen Policy #5411 (www.svsu.org) and how to obtain a copy of the Exposure Control Plan (ECP).
  • An explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident.
  • An explanation of the use and limitations of exposure controls, work practices, and Personal Protective Equipment (PPE).
  • An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE.
  • An explanation of the basis for PPE selection.
  • Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge.
  • Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious material (OPIM) will be made available.
  • An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
  • Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident.
  • An explanation of the signs and labels and/or color-coding required by the policy/standard and used at this facility.
  • An opportunity for interactive questions and answers with the person conducting the training session.
Training records are completed for each employee upon completion of training. These documents will be kept for each building with the school administration (See Appendix B).

The training records include:
  • The dates of the training sessions.
  • The contents or a summary of the training sessions.
  • The names and qualifications of persons conducting the training.
  • The names and job titles of all persons attending the training sessions.

Medical Records

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, “Access to Employee Exposure and Medical Records.”

The SVSU Human Resources Department is responsible for maintenance of the required medical records.

Exposure Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA’s Recording Requirements (29 CFR 1904). This determination and the recording activities are done by the SBSU Human Resource Department.

Sharps Injury Log

In addition to the 1904 Recordkeeping Requirements, all injuries from contaminated sharps are also recorded in a Sharps Injury Log (See Appendix C). All incidences must include at least:
  • Date of the injury.
  • Type and brand of the device involved (syringe, suture needle, etc.).
  • Department or work area where the incident occurred.
  • Explanation of how the incident occurred.
This log is review as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

Required School Nurse/Associate School Nurse Role

  • Review school’s bloodborne pathogens exposure control plan; alert administration of new guidelines as necessary.
  • Develop safe practices for disposal of needles, other sharps and contaminated waste.
  • Establish procedures for use of person protective equipment for cleaning blood and body fluid spills and proper disposal; inform appropriate staff in procedure as needed.
  • Ensure that sink used for cleaning of blood injuries is located away from refrigerator, medicine cabinet and any eating surfaces.
  • Annual additional training for all staff and additional training for members at higher risk for exposure.
  • Work with maintenance/custodial staff to ensure proper annual training.

Responsibilities by assignment:

Teachers and Staff Members:

  • Avoid contact with all blood and body fluids.
  • If Necessary use personal protective equipment (PPE) following universal precautions.
  • Remove children from exposure.
  • Bring injured/exposed person to the nurse.]
  • Call the custodian for clean-up.
  • Report any exposure to the nurse and principal.
  • Complete incident report if exposed.

Maintenance/Custodial Role:

  • Respond immediately to all calls for blood or body fluid spills.
  • Follow universal precautions-use PPE as necessary.
  • Follow appropriate protocols for clean up as outlined in OSHA recommendations.
  • Follow sharps protocol.
  • Safe containment of hazardous materials.
  • Maintenance/Custodial Directors: Ensure annual trainings in proper protocols, ECP, and use of cleaning materials.

Principal/Administration Responsibilities:

The SVSU is responsible for implementation of the ECP. The Superintendent, or his/her designee will maintain, review, and update the ECP at least annually with input from the school nurses of the SVSU, and whenever necessary to include new or modified tasks and procedures.
The Principal will ensure that the school will provide and maintain all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. The principals will also ensure that adequate supplies of the equipment are available in the appropriate sizes.
  • The Principal will be responsible for ensuring that all medical actions required by the standard are performed and that appropriate employee health and OSHA records are maintained.
  • The School Principal will be responsible for training, documentation of training, and making the written ECP available to employees.

Human Resources Responsibilities:

  • Responsible for ensuring all new hires and substitute employees have required training on policy #5411.
  • Responsible for documentation of all employee compliance with annual training on policy #5411.
  • Follow-up, monitor and maintain records of employee exposures.
  • Maintain records of all employee hepatitis B immunizations or refusal of vaccination form (see Appendix A).

Appendix A
Southwest Vermont Supervisory


I, __________________, understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

____________________                 ___________
Employee signature                                 Date

____________________                 ___________
Administrator signature                             Date

Southwest Vermont Supervisory Union
Exposure Control Plan Training

Facilitator:__________________             Title/Position:_________________
Date: _____________    Start time: __________    End Time:_____________

 Name    School or Building  Job Title/Position