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PRE-APPUCAMON QUESTIONNAIRE <br /> Please check the appropriate response for the questionslisted below. <br /> REGULATED MEDICAL WASTES <br /> ( to • specimen or microbiologic cultures, stoc of infectious agents, <br /> Eve attenuated vaccines, mediums <br /> ( 1 or Body Fluids - liquid bloodelements or other regulated body fluids, or <br /> 'cies contaminated loo s <br /> ( harps - syringes, needles, blades, broken glass <br /> ( ) t to carcasses, o s, bedding materials <br /> ( u <br /> urgical Specimens - human or animal parts or tissues removed surgically or by <br /> autopsy <br /> ( <br /> Isolation - waste contaminated 't excretion, exudate, or secretions from <br /> humans or animals who are isolated due only to the highly communicable diseases <br /> listed by Centers for Disease Control as requiring Biosafety Level 4 precautions.* <br /> 1. Does your business or service a er f <br /> e medical wastes lists oe yes o® <br /> If your answer is no, please complete the "Certification Stat t" on Page <br /> 5 and return it with this questionnaire to the address indicated. You do not <br /> need to complete the remainder of this questionnaire. <br /> If your answer isyes, please check the es(s) of waste listed above that <br /> you or your facility generate. Please complete the rest of this questionnaire. <br /> 2. Do you generate less than 200 poundsf medical <br /> waste permonth? if yes, you are a small <br /> generator. yes—no <br /> . Small generators may store their medical waste <br /> in a permitted common storage facility 'th <br /> other small generators. Do you plan to do this <br /> t your facility? yes—no <br /> If your er is 3M a PHS-EHD "Common Storage Facility Permit <br /> Application!' e mailed to you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -CONTINUEDE- <br />