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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 /> Blood or Body FIuids liquid blood elements or other regulated body fluids, or articles <br /> contaminated with blood or body fluids <br /> ,k 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 /> () Isolation 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 /> * 8ionfery Level a viruses and disasa aro:Cogs-Crimean Hemorrhagic Fera.Ti -borne Fsapiwitis Vine Complex(Absaww.Ha®lom Hypr.Kumliagq Kyasanur Face Dish <br /> Omsk Hemorrhagic Fever.and Russian Spring-Summa Encephalitisâ–ş,Masburs Disesse,abols.Junin Vine,Lusa Fcver V'mm and Maebupo Vuus. <br /> 1. Does your business or service generate any of the medical wastes listed above? yes_ no_ <br /> If your answer is no, please complete the "Certification Statement" on Page 3 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 the rest of this questionnaire. <br /> 2. Do you generate 200 pounds or more of medical waste per month? yesno_ <br /> 3. Do you plan to treat your medical waste onsite t your facility), by autoclaving, incinerating or <br /> using microwave technology? yes_no <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, transport 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 />