Fillable SECTION I: TYPES OF MEDICAL WASTE GENERATED (Check (Contra Costa Health Services)

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SECTION I: TYPES OF MEDICAL WASTE GENERATED (Check (Contra Costa Health Services)

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1
Last Updated 2/10/20
Per sections 117935, 117945 & 117960 of the California Health & Safety Code, small and large quantity generators of medical waste must maintain a
Medical Waste Management Plan.
BUSINESS NAME:
BUSINESS ADDRESS:
BUSINESS PHONE:
FAX:
BUSINESS E-MAIL:
AUTHORIZED REPRSENTATIVE:
SECTION I: TYPES OF MEDICAL WASTE GENERATED (Check all that apply)
Blood or body fluids – liquid blood elements or other regulated body fluids or articles contaminated with blood or body fluids.
Chemotherapy waste
Contaminated animals – animal carcasses, body parts, bedding materials.
Isolated waste – waste contaminated with excretion, exudate or secretions from humans or animals that are isolated due to highly
communicable diseases (**Centers for Disease Control, Biosafety Level 4**).
Laboratory wastes –specimen or microbiological cultures, stacks of infectious agents, live and attenuated vaccines and culture
mediums, vials or vacutainers containing blood or blood products.
Pharmaceutical waste (not including chemotherapeutic, antineoplastic, or cytotoxic drugs)
Sharps – syringes, needles, blades, and broken glass.
Surgical specimens – human or animal parts or tissues removed surgically or by autopsy. (Anatomical or Pathology Waste)
**Note: Biosafety Level 4 viruses and diseases are Congo-Crimean hemorrhagic fever, Tick-borne encephalitis virus complex
(Absettarov, Hanzalova, Hypr, Kumlinge, Kyasanur Forest Disease, Omsk Hemorrhagic Fever, and Russian Spring-Summer
Encephalitis), Marburg Disease, Ebola, Junin Virus, Lassa Fever Virus, and Machump Virus.
SECTION II: FACILITY INFORMATION
1. This facility is classified as a (check one):
2. The estimated quantity of medical waste generated (including sharps waste) by this facility on a monthly basis is ___________ lbs.
3. Complete the following for the registered medical waste hauler contracted by your facility:
NAME:
ADDRESS:
CITY / STATE / ZIP:
PHONE:
SECTION III: TRAINING
4. Describe the types of training provided to employees that handle medical waste at your facility.
5. Describe the frequency of training provided to the employees that handle medical waste at your facility.
Med/Dent/Vet Clinic (> 200 lbs./month)
Acute Care Hospital (1-99 beds)
Biomed Producer (> 200 lbs./month)
Med/Dent/Vet Clinic (< 200 lbs./month)
Acute Care Hospital (100-199 beds)
Biomed Producer (< 200 lbs./month)
Med/Dent/Vet Clinic w/ On-site Treatment (>200 lbs./month)
Acute Care Hospital (200-250 beds)
Common Storage Facility (2-10 generators)
Med/Dent/Vet Clinic w/ On-site Treatment (< 200 lbs./month)
Acute Care Hospital (251+ beds)
Common Storage Facility (11-49 generators)
Skilled Nursing Facility (> 200 lbs./month)
Health Care Service Plan
Clinical Laboratory (> 200 lbs./month)
Skilled Nursing Facility (< 200 lbs./month)
Specialty Clinics
2
Last Updated 2/10/20
SECTION IV: FACILITY PROCEDURES
6. Describe the methods of handling and collection of medical waste within your facility.
7. Describe the steps taken to properly categorize DEA “controlled substance” and/or RCRA hazardous pharmaceutical waste that is
generated. If not applicable mark “N/A”.
8. Describe the method of storage of medical waste within your facility.
9. Describe the procedures used in your facility for the cleanup of medical waste spills.
10. Describe the use of any disinfection procedures used in your facility for of cleaning of reusable medical waste receptacles.
11. If your facility employs a method of on-site treatment (i.e. autoclave, incineration, steam sterilization) for medical waste, enclose the
operating procedures for the equipment and closure plan. If enclosing documents write “See Attached” in this section.
**Note: If ONLY reusable medical instruments or equipment are treated on-site, mark this section as “N/A”.
SECTION V: EMERGENCY DISPOSAL
In case of emergency, such as equipment breakdown on the part of the registered hauler or natural disaster, medical waste will be
EITHER (check one):
Stored for up to seven days on the premises. Sufficient storage space is available in ____________________________________.
The following alternate registered biohazardous waste hauler will be utilized:
NAME:
ADDRESS:
CITY / STATE / ZIP:
PHONE:
In the event of an emergency or natural disaster, contact Contra Costa Environmental Health (CCEH) at (925) 608-5500 to notify CCEH
of any changes or to obtain further instruction(s).
SECTION VI: TERMS / SIGNATURE
Under penalty of law I declare that to the best of my knowledge and belief the information that I have provided is true and accurate.
When any of the information in this plan changes, I will submit an updated plan within 30 days. I also agree to conform to all conditions,
orders, and directions issued pursuant to the California Health and Safety Code, Section 117600 – 118360 (The Medical Waste
Management Act) and all applicable local ordinances.
Signature of Applicant: ___________________________________________________________ Date: ______________________
Print Name: ___________________________________________________________
MEDICAL WASTE MANAGEMENT PLAN
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SECTION I: TYPES OF MEDICAL WASTE GENERATED (Check (Contra Costa Health Services)

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Completed 10 January 2021

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