Healthcare Bio Waste Form

HEALTHCARE BIOWASTE MANIFEST AND HANDLING FORM

This manifest documents generation, handling, storage and transfer of regulated biohazardous waste. The generator certifies that the material described below has been segregated, contained, labeled and stored in accordance with applicable regulations and facility policies. The generator further certifies that no incompatible wastes are mixed, and that sharps are placed in approved puncture-resistant containers. Retain a copy of this form until final treatment or disposal is documented.

Facility / Generator Information

Patient / Source Information (if applicable)

Patient Name:    Medical Record #:

Date of Birth:    Sex:    Bed/Room #:

Waste Description and Segregation

Date of Generation:    Time of Generation:

Select Waste Type(s):

Handling, Special Precautions and Notes

Transport / Pickup Information

Scheduled Pickup Date:    Pickup Time:

Generator Certification

I hereby certify that the waste described on this manifest was generated at the named facility, has been segregated and packaged in accordance with applicable regulations and facility protocols, and is accurately described. I further certify that no waste is knowingly mixed with incompatible waste streams and that required labeling, container integrity, and handling instructions are provided to the transporter. In the event of an incident or release, the generator agrees to notify appropriate emergency contacts and to cooperate with containment and reporting requirements.

Additional Notes / Attachments

Sign Now