Needs Assessment PurchaserPurchaser Name* First Last Purchaser Title*Purchaser Email* Purchaser Phone*FacilityFacility Name*Type of Facility*Facility Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility Phone*Number and size of waste disposal containers needed:Small = 17 gallonMedium = 43 gallonLarge = 95 gallonNumber and size of sharps containers needed:1 quart5 quart5.4 quart2 gallon8 gallonFrequency of pick up:Per weekPer monthPer quarterPer yearWhat type of waste is being generated? Sharps including any object capable of cutting, protruding, or penetrating its packaging: needles, syringes, scalpels, blades, broken glass, broken pipettes, dental wires, and sharp plastic. Disposable items generated int he treatment of humans or animals with a known or suspected communicable disease: gowns, gloves, drapes, IV tubing, suction canisters, etc. Blood, blood products, or items saturated with blood so that it is wet or dripping such as bandages, dressings, and other disposable products. Body fluids removed during surgery, autopsy, or other medical procedures; and/or specimens of body fluids and their containers; and/or discarded materials saturated with body fluids (other than urine). Laboratory cultures and disposable items used in a laboratory setting. Pathological waste - recognizable human and/or vertebrate animal derived tissues, organs, and body parts,(excluding teeth and contiguous structures of bone and gum and body fluids). Teeth without amalgam. Pharmaceuticals: partial creams, ointments, partial vials, ampules, partially filled syringes, discontinued IVs with non-hazardous pharmaceuticals. Chemo Soft: gowns, gloves, masks, IV tubings. Chemo Sharps: trace chemotherapy waste, vials (empty/trace), syringes/needles (empty/trace), trace chemotherapy sharps, IVs (empty/trace). Current monthly price:Other services being received as part of the medical waste disposal package:Other services desired as part of the medical waste disposal package:Who do you currently use for your OSHA Compliance training and certification?What do you like about your current service?What would you change about your current service?How long have you been with your existing company?Please provide a copy of the most recent medical waste disposal contract and most recent invoice.
