Needlestick Injuries and Other Blood-borne and/or Body Fluid Pathogen Exposures Policy


To educate about, prevent, and address student blood and /or body fluid exposures


All healthcare workers are at potential risk from exposure to blood and/or body fluids. Students must be educated about risks, prevention, and treatment of exposures. It is recommended that Universal Precautions be adopted whenever there is the potential for exposure to reduce the risk of transmission of pathogens. There are validated protocols to reduce the risk of transmission in the event of an exposure to HIV, HBV, or HCV; an accessible, clear protocol must be outlined and disseminated to all students.

Related LCME Standards

12.8: Student Exposure Policies/Procedures


The education of medical students about methods exposure prevention; procedures for care and treatment after exposure; definition of financial responsibility in care and treatment; and the effects of infectious and environmental disease or disability on learning activities must all be addressed.



  1. Students are introduced to the concept of infection control and work-related exposure during their first year of medical school. Education and training regarding exposures will be updated annually throughout medical school.
  2. Students, including visiting students, must contact the UCSF Needlestick Hotline 24 hour pager immediately in the event of an exposure to blood and / or bodily fluid. The contact number [(415) 353-STIC (7482)] is listed on the student ID insert.
  3. There are standardized protocols for exposures at UCSF / in San Francisco and at non-UCSF facilities / our-of-area facilities addressing exposure to HIV, HBV and HCV. Financial coverage of treatment is outlined in the protocol:
  4. Students who are infected with any other potentially transmissible disease will not be excluded from participating in patient-care activities, or restricted in their access to patient-care services or facilities because of their health status, unless medically-based judgments in individual cases establish that exclusion or restriction is appropriate for the welfare of patients, the welfare of other members of the patient-care community, or the welfare of the individual. 



  1. Needlestick procedures are included in a mandatory policy attestation process for students.* These procedures are posted on the policy page on the UCSF website and included in links within the iRocket system.
  2. Information about the Blood and Body Fluid Exposure policy is included on student badges distributed during Physician Identity/ARCH week 1. 
  3. Blood and Body Fluid Exposure procedures are introduced during the Clinical Microsystem Clerkship Procedures session (122C).
  4. During orientation to the clerkships, clerkship directors/site directors review needlestick procedures with students. Effective 2018*, students also re-attest to understanding this policy prior to starting their clerkships.  

*For the 2018-19 academic year, this attestation occurred in October 2018.

Accountable Dean or Director:

Associate Dean for Students
Executive Director, Assessment, Curriculum, Evaluation (incorporation into curriculum)
Director of Student Experience Team (visiting students)

Approval Date and Governing Body:  April 17, 2018, CCEP

Last Updated: October 16, 2018