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PRE-APPLICATION QUESTIONNAIRE <br /> Regulated Medical Wastes <br /> Please check the appropriate box for the questions listed below: <br /> Pharmaceuticals: prescription or over-the-counter human or veterinary drug, including, but not limited to, a <br /> drug as defined in Section 109925 of the Federal Food, Drug, and Cosmetic Act, as amended [21 U.S.C.A. <br /> Sec. 321(g)(1)]. This definition does not include RCRA waste. <br /> Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and attenuated <br /> vaccines and culture mediums. <br /> Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with blood <br /> or body fluids. <br /> Sharps: syringes,needles,blades and contaminated broken glass. <br /> ❑ Contaminated Animals: animal carcasses, tissues, and fluids contaminated with infectious agents that are <br /> contagious to humans. <br /> Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy that are <br /> contaminated with infectious agents that are contagious to humans or in a fixative(e.g. formaldehyde). <br /> Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals that <br /> are isolated due to highly communicable diseases. <br /> Chemotherapy Wastes: waste contaminated through contact with chemotherapeutic agents. <br /> 1. Does your business or service generate any of the medical waste listed above? Yes❑No <br /> If your answer is "No", please complete the "Certification Statement" on Page 3 <br /> and return it with this questionnaire to the address indicated. You do not need to <br /> complete the remainder of this questionnaire and you do not need to pay a fee. <br /> 2. Do you generate less than 200 pounds of medical waste per month? ❑Yes No <br /> If you answered"Yes",you are a small generator. <br /> 3. Small generators may store their medical waste in a permitted Common Storage <br /> Facility with other small generators. Do you plan to do this at your facility? ❑Yes No <br /> If your answer is "Yes", you must obtain a "Common Storage Facility Permit' <br /> from this office. <br /> 4. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, <br /> incinerating or using microwave technology? Yes❑No <br /> If you are a small generator and your answers to question 3 & 4 are "No", then <br /> complete the "Certification Statement' on Page 3 and return it with this <br /> questionnaire to the letterhead address. You do not need to complete the rest of this <br /> package. <br /> If your answer is "Yes", you must complete Pages 4-8 and return them with this <br /> questionnaire and the appropriate fee(see Page 9)to the address indicated on Page 1. <br /> EHD 45-03 2 <br /> 2015 <br />