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Environmental Health Department <br />PRE -APPLICATION QUESTIONNAIRE <br />Regulated Medical Wastes <br />Please check the appropriate box for the questions listed below: <br />❑ Pharmaceuticals: prescription or over-the-counter human or veterinary drug, including, but not limited to, a drug as <br />defined in Section 109925 of the Federal Food, Drug, and Cosmetic Act, as amended [21 U.S.C.A. Sec. 321(g)(1)]. <br />This definition does not include RCRA waste. <br />❑ Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and attenuated vaccines <br />and culture mediums. <br />❑ Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with blood or body <br />fluids. <br />Sharps: syringes, needles, blades and contaminated broken glass. <br />❑ Contaminated Animals: animal carcasses, tissues, and fluids contaminated with infectious agents that are <br />contagious to humans. <br />❑ Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy that are contaminated with <br />infectious agents that are contagious to humans or in a fixative (e.g. formaldehyde). <br />❑ Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals that are <br />isolated due to highly communicable diseases. <br />❑ Chemotherapy Wastes: waste contaminated through contact with chemotherapeutic agents. <br />1. Does your business or service generate any of the medical waste listed above? Yes ❑No <br />If your answer is "No", please complete the "Certification Statement" on Page 3 and return it <br />with this questionnaire to the address indicated. You do not need to complete the remainder of <br />this questionnaire and you do not need to pay a fee. <br />2. Do you generate less than 200 pounds of medical waste per month? ❑ Yes No <br />If you answered "Yes", you are a small generator. <br />3. Small generators may store their medical waste in a permitted Common <br />Storage Facility with other small generators. Do you plan to do this at your <br />facility? ❑ Yes No <br />If your answer is "Yes", you must obtain a "Common Storage Facility Permit" from this office. <br />4. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, incinerating or <br />using microwave technology? ❑ Yes No <br />If you are a small generator and your answers to question 3 & 4 are "No", then complete the <br />"Certification Statement" on Page 3 and return it with this questionnaire to the letterhead <br />address. You do not need to complete the rest of this package. <br />If your answer is "Yes", you must complete Pages 4-7 and return them with this questionnaire <br />and the appropriate fee (see Page 8) to the address indicated on Page 1. <br />2of8 <br />