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PRE-APPLICATION QUESTIONNAIRE <br /> REGULATED MEDICAL WASTES <br /> (check all that apply) <br /> Laboratory Wastes - specimen or microbiologic cultures, stocks of infectious agents, live and <br /> attenuated vaccines, and culture mediums <br /> (x) Blood or Body Fluids - liquid blood elements or other regulated body fluids, or articles <br /> contaminated with blood or body fluids <br /> Sharps -syringes,needles,blades, broken glass <br /> Contaminated Animals -animal carcasses, body parts,bedding materials <br /> Surgical Specimens-human or animal parts or tissues removed surgically or by autopsy <br /> 0Isolation Wastes - waste contaminated with excretion, exudate, or secretions from humans or <br /> animals who are isolated due only to the highly communicable diseases listed by Centers for <br /> Disease Control as requiring Biosafety Level 4* precautions. <br /> * 3wsafecy Level 4 vine=and d--am C00990-CCIMCNA K9M0ffh9VG Fever.TiZnc=Wm Vv=Complex(Absedarov.Hatuaiw4m.Hypr.Kumfi0jr,KYUSZOW FOMU 015c"d. <br /> Omsk Henn rta Fever.and Rum=SfKmOummwF�aphdimL Dogem Sol&lupin Virtm Lmn Fever Tmw=4 Machum Vim& <br /> 1. Does your business or service generate any of the medical wastes listed above? yes-i no_ <br /> If your answer is no, please complete the "Certification Statement" on Page 37 and return it with this <br /> questionnaire to the address indicated. You do not need to complete the remainder of this questionnaire. <br /> If your answer is ves, please check the types(s) of waste listed above that you or your facility generate. <br /> Please complete therestof this questionnaire. <br /> 2. Do you generate 200 pounds or more of medical waste per month? yes X no_ <br /> .0 <br /> Do you plan to treat your medical waste onsite (at v ur facility), by autoclaving, incinerating or <br /> using microwave technology? yes_no X <br /> If your answers to questions 2 and 3 are no, then complete the "Certification Statement" on Page 3 and <br /> return it with this questionnaire to the address shown at the bottom of Page 1. <br /> If your answers to questions 2 or 3 are ves complete the "Registration/Permit Application For <br /> Medical Waste" form on Page 4 and submit a"Medical Waste Management Plan" as specified on <br /> Page 5. <br /> 4. If you generate less than 20 pounds of medical waste per week,amnsport less than 20 pounds <br /> at one time, and have a hauling information document on file in your office, you may apply <br /> for a Limited Quantity Hauling Exemption. This exemption allows you or your staff to transport <br /> medical waste to a medical waste treatment facility or to a consolidation point until it can be <br /> removed by a registered medical waste hauler. Do you want to apply for a Limited Quantity <br /> Hauling Exemption? yes_no_ <br /> If your answer is ves, a "Limited Hauling Exemption" application will be mailed to you. <br /> 2 <br />