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e 4 <br /> PRE-APPUCAUON QUESTIONNAIRE <br /> Please check the appropriate response for the questions listed below. <br /> REGULATED MEDICAL WASTES <br /> OLaboratory Wastes-specimen or 'croiologic cultures, stocks of infectious agents, <br /> live and attenuated vaccines, and culture mediums <br /> Bloodor Body Fluids - liquid blood elements or other regulated body fluids, or <br /> articles contaminated ° blood or body fluids <br /> S - syringes, nee es, blades, broken glass <br /> OContaminated <br /> - al carcasses, body s, bedding materials <br /> O S - or animalp s or tissues removed surgically or by <br /> autopsy <br /> Isolation Wastes - waste contaminated 't excretion, exudate, or secretions from <br /> ry 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 /> 1. Does your business or service generate any of to <br /> e medical wastes listed above? y no_, <br /> If your wer is n,_o please complete the "Certification Stat t" 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 er is 3m please check the es(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--A <br /> I Small generators may store their medical waste <br /> in a permittedcommon storage facility with <br /> other small generators. Do you plan to do this <br /> at your facility? yes®no® <br /> If your wer is M a PHS-EHD "Common StorageFacility Permit <br /> Application!' will be mailed to you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -CONTINUE D ON REVE ME- <br /> 3 <br />