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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 /> 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 /> L&j <br /> R Contaminated Animals: animal carcasses,body parts and bedding materials. <br /> E] Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy. <br /> El 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 /> 1. Does your business or service generate any of the medical waste listed above? XYes E] 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? EJ Yes;K 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.? El Yes&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? El Yes 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? El Yes No <br /> EHD 45-02-003 Page 2 of 7 <br /> 10/6/2003 <br />