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0 <br />EM <br />.. .. • i "I P <br />Please check the appropriate response for the questions listed below. <br />REGULATED MEDICAL <br />Laboratory Wastes - r or •r a •gic cultures, stocks of •agents,live • attenuated vaccines, and culture mediums <br />(vY Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br />articles contaminated blood or body fluids <br />(V,( Sharps - syringes, needles, blades, broken glass <br />Contaminated Animalsbody parts, bedding <br />autopsy(v)- Surgical Specimens - human or animal parts or tissues removed surgically or by <br />isolation Wastes - waste contaminated with excretion, exudate, or secretions from <br />humans or animals who are isolated due only to the highly communicable diseases <br />listed by Centers for Disease Control as requiring Biosafety Level 4 precautions.* <br />Doesyour business or • ;.. <br />medicalthe • »r• •` <br />if your answer is no, please• :. r .. the "CertificationStatement*on Page <br />5 and return it with this questionnaire to the address indicated. You do not <br />need to complete the remainder of this questionnaire. <br />If your answer is 3M please check the types(s) of waste listed above that <br />you or your facility generate. Please complete the rest of this questionnaire. <br />2. Do you generate less than 200 pounds of medical <br />waste per • you <br />generator. • <br />I Small generators may storemedical <br />in a r- -d common storage <br />other small generators. Do you plan to do this <br />at your • <br />If your - :w; PHS-EHD "common storageM Permit <br />Application!'be, • to you.Please indicate if you want the <br />application mail-+ <br />-CONTINUED ON REVERSE <br />0 <br />