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007.05.7 Form 1. Medical Waste Release and Accident Report

AR ADC 007.05.7 Form 1Arkansas Administrative CodeEffective: January 1, 2017

West's Arkansas Administrative Code
Title 007. Department of Health
Division 05. Health Facility Services
Rule 7. Rules and Regulations Pertaining to the Management of Medical Waste from Generators and Health Care Related Facilities
Effective: January 1, 2017
Ark. Admin. Code 007.05.7 Form 1
007.05.7 Form 1. Medical Waste Release and Accident Report
Currentness
All incidents involving the release of medical waste to the environment or other incidents/accidents involving commercial medical waste shall be reported verbally as soon as possible but within twelve (12) hours to the Department with a follow-up written report on this form in five (5) working days from the incident as required by the Rules and Regulations Pertaining to the Management of Medical Waste from Generators and Health Care Related Facilities. The Department shall be notified at (501) 661-2621 or (501) 661-2000 during working hours and (501) 661-2136 after normal working hours.
I. Information relating to the transporter, handler, treatment storage and/or disposal (TSD) facility or mobile treatment system:
1. Company Name: _______________________________________________________
2. Mailing Address: _______________________________________________________
3. Company Owner: _______________________________________________________
4. Contact Person on Matters Related to Regulatory Compliance:
Name: _______________________________________________________
Telephone #: _______________________________________________________
5. Contact Person for Emergencies:
Name: _______________________________________________________
Telephone Number: _______________________________________________________
II. Information Related to the Release or Accident:
6. Date of the Release/Accident: _____________________________________________
7. Time of the Release/Accident: _____________________________________________
8. Amount and Type of Medical Waste Involved:
____________________________________________________________
 
_
9. Location of the Release/Accident:
____________________________________________________________
 
_
10. Description of the Release/Accident:
11. Description of Clean-up & Decontamination:
12. Name and Address of Employees (and any other persons) involved in the Cleanup Efforts:
13. Company Official Completing this Release/Accident Report:
Name & Title: ____________________________________________________________
____________________________________________________________
 
Signature: ____________________________________________________________
Date: ____________________________________________________________
Mail or Fax Completed Report To:
Arkansas Department of Health
Medical Waste Program
4815 W. Markham, Slot 32
Little Rock, AR 72205-3867
Phone (501) 661-2621 Fax (501) 280-4090

Credits

Amended Sept. 5, 2013; Jan. 1, 2017.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.05.7 Form 1, AR ADC 007.05.7 Form 1
End of Document