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. 00. <br /> PRE-APPUCAMON QUESTIONNAIRE <br /> Please check the appropriate response for the questions listed below. <br /> REGULATED MEDICAL WASTES <br /> OLaboratory Wastes-specimen or microbiologic cultures, stocks of infectious agents, <br /> live and attenuated vaccines, and culture mediums <br /> ( Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br /> articles contaminated blood or body fluids <br /> ( s syringes, needles, blades, broken glass <br /> Contaminated Anima - carcasses, body parts, bedding materials <br /> O 'c Specimens - o s or tissues removed surgically or by <br /> autopsy <br /> OIsolation Wastes - waste contaminated 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 generate any of <br /> e medical wastes listed above? o_ <br /> If your er is no,please complete the "Certffication 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 youranswer is 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 pounds of medical <br /> waste permonth? If yes, you are a small <br /> generator. yes--nq x <br /> 3. Small generators may store their medical waste <br /> in a permittedcommon storage facility with <br /> others all generators. Do you plan to do this <br /> at your facility? yes <br /> If your er P S- "Common Storage Facility Permit <br /> Application!' will be mailed to you. Please indicate if you want the <br /> application mailed elsewhere. y� <br /> -CONTINUED REVERSE- <br /> 3 <br /> 0 !.- <br />