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• <br />• <br />♦ � v <br />-d .v <br />It <br />�`3 V � I � P> <br />3 <br />PRE -APPLICATION QUESTIONNAIRE ` p <br />Please check the appropriate response for the questions listed below. <br />REGULATED MEDICAL WASTES <br />() Laboratory Wastes - specimen or microbiologic cultures, stocks of infectious agents, <br />live and attenuated vaccines, and culture mediums <br />)14 Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br />articles 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 <br />autopsy <br />Isolation Wastes - waste contaminated with excretion, exudate, or secretions from <br />humans or animals who are isolated due only to the highly communicable diseases <br />listed by Centers for Dis ase Con of as requiring Biosafety Lev l A precautions.* <br />4904-1 T ICA -Ll it <br />1. Does your business or service generate any of <br />the medical wastes listed above? yes�no_, <br />If your answer is no, please complete the "Certification Statement" 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 is 3M please check the types(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 pounds of medical <br />waste per month? If yes, you are a small <br />generator. yes no_ <br />3. Small generators may store their medical waste <br />in a permitted common storage facility with <br />other small generators. Do you plan to do flus <br />at your facility? yes_no <br />If your answer is yes, a PHS-EHD <br />Application" will be mailed to you. <br />application mailed elsewhere. <br />-CONTINUED ONREVERSE- <br />"Common Storage Facility Permit <br />Please indicate if you want the <br />3 <br />