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PRE-APPLICATION QUESTIONNAIRE <br /> Regulated Medical Wastes <br /> Please check the appropriate box for the questions listed below: <br /> ❑ Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents,live and <br /> attenuated vaccines and culture mediums. <br /> Z Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with <br /> blood or body fluids. <br /> Sharps: syringes, needles,blades and contaminated broken glass. <br /> ❑ Contaminated Animals: animal carcasses,body parts and bedding materials. <br /> Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy. <br /> <Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals <br /> who are isolated due only to the highly communicable diseases listed by the Centers for Disease <br /> Control as requiring Biosafety Level IV precautions. <br /> I Does your business or service generate any of the medical waste listed above? 0 Yes❑No <br /> If your answer is "No",please complete the "Certification Statement"on Page <br /> 4 and return it with this questionnaire to the address indicated. You do not need <br /> to complete the remainder of this questionnaire. <br /> 2. Do you generate less than 200 pounds of medical waste per month? ❑Yes N No <br /> If you answered"Yes", you are a small generator. <br /> 3. Small generators may store their medical waste in a permitted Common Storage <br /> Facility with other small generators.Do you plan to do this at your facility? ❑Yes C9 No <br /> If your answer is "Yes", you must obtain a"Common Storage Facility Permit" <br /> from this office. <br /> 4. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, <br /> incinerating or using microwave technology? ❑Yes 0 No <br /> If you are a small generator and your answers to question 3 &4 are"No", then <br /> complete the "Certification Statement"on Page 3 and return it with this <br /> questionnaire to the letterhead address. You do not need to complete the rest of <br /> this package. <br /> If your answer to this question is"Yes",you must complete Pages 4&5 and <br /> return them with this questionnaire and the appropriate fee to the address <br /> indicated on Page 1. <br /> 5. If you generate less than 20 pounds of medical waste per week, transport less <br /> than 20 pounds at one time, and have a hauling information document on file in <br /> your office, you may apply for a Limited Quantity Hauling Exemption from this <br /> office.This exemption allows you or your staff to transport medical waste to a <br /> medical waste treatment facility.Do you want to apply for a Limited Quantity <br /> Hauling Exemption? ❑Yes No <br /> EHD 45-02-003 Page 2 of 7 <br /> 1016/2003 <br />