Laserfiche WebLink
5 <br />28 <br />-T <br />PRE <br />-APPUIC� <br />'no ONNAIRE <br />Please check the appropriate response for the questions listed below. <br />I twelli IVAN V <br />Laboratory Wastes - specimen or microbiologic cultures, stocks of infectious agents, <br />live and attenuated vaccines, and culture mediums <br />Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br />articles contaminated with blood or body fluids <br />Sharps - syringes, needles, blades, broken glass <br />t Animals - animal carcasses, body parts, bedding materials <br />Surgical Specimens - human or animal parts or tissues removed surgically or by <br />autopsy <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 />1 Does your business or service generate any of <br />the medical wastes listed above? yes2hq_ <br />If your answer is no. Please complete the "Certification Statement" 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 yes, please check the types(s) of waste listed above that <br />you or I 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. yes2hq- <br />3. Small generators may store their medical waste <br />in a permitted common storage facility with <br />other small generators. Do you plan to do this <br />at your facty? ye• <br />If your answer is M a PHS-Eon Storage Facility Permit <br />Application!' will be mailed to you. Please indicate if you want the <br />application mailed elsewhere. <br />-CONTINU M- ON REVERSE - <br />3 <br />