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PRE -APPLICATION QUESTIONNAIRE <br />Please check the appropriate response for the questions listed below. <br />BloodLaboratory Wastes - specimen or microbiologic cultures, stocks of infectious agents, <br />live and attenuated vaccines, and culture mediums <br />or i r• liquid ► ••t elements or ► •` <br />r regulated body fluids, or <br />articles contaminated with blood or ►o <br />dy fluids <br />S=-psyringes,needles, blades, broken <br />ontaminated Animals - animal carcasses,## parts,bedding materials <br />• r r r. • s +. -n• 't • r <br />Surgical r`r. tr: ai.human.. <br />autopsy <br />isolation Wastes - waste contaminated with excretion, exudate, or secretions from <br />humans or r. who are isolated due only • the highly communicablediseases <br />listed by • Disease Control as requirings precautions.* <br />1. Does your business or service generate any of <br />the medical wastes listed above? yesZno— <br />if your answer is no, please• tt r"Certification Statemenf • t <br />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 yes, 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 month? if yes, you are a small <br />generator. yes no <br />generatorsSmall may store their medical <br />in a permitted c•i• • facility • <br />othergenerators. i • you plan • t • this <br />at • <br />rFacility PermitCom=on Storage <br />Application7 will be mailed to you. Please indicate if you want the <br />application m. t elsewhere. <br />-CONT29M ON REVERSE- <br />fc3 <br />