Laserfiche WebLink
s <., 0 <br /> 00 <br /> PRE-APPLICATION QUESTIONNAIRE <br /> Please check the appropriate response for the questions listed below. <br /> REGULATED I <br /> ( ) Laboratory 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 with blood or body fluids <br /> (Jf S - syringes, needles, blades, broken glass <br /> Contaminated Animal - carcasses, body parts, bedding materials <br /> O S S - 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 Disease Control as requiring Biosafety Level 4 precautions.* <br /> 1. Does your business or service generate any of <br /> the medical wastes listed above? y 2np— <br /> If your er 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 er isyes, please checkthe 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 per month? If yes, you are a small <br /> generator. yes <br /> 3. 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 /> at your facility? yes® o <br /> If your answer is 3M a PHS-EHDo Storage Facility Permit <br /> Applicatiod will be mailed to you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -CONTINLM <br /> ON ° B E- <br />