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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 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 /> { ) 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 /> *• Biosafety Level 4 Vi[u n and dL==are: Congo-crmma Hemorrhagic Fever.rKk.borM F.nmphaiids Virus Cathie:(Abunmv,Hutaiova,Hypr,Kumiiage,Kyasatatr Fast Doan, <br /> Omsk Hemorrhagic Fever,ud Auniaa Spring-Summa Enceptaiith),Marburg Disease,Ebola,Jwdn Yirw.LIM Ftver Vitus,sad Madapa Vista. <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 yes, 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? yes— no <br /> 3. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, incinerating or <br /> using microwave technology? yes— no`7- <br /> If your answers to questions 2 and 3 are no, then complete the "Certification Statement" on Page 3 <br /> and 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 M, complete the "Registration/Permit Application For <br /> Medical Waste" form on Page 4 and submit a "Medical Waste Management PIan" 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 yes, a "Limited Hauling Exemption" application will be mailed to you. <br /> 2 <br />