Name of Hospital/Clinic/Laboratory ______________________ Owner ___________________

Location ____________________________________________ Date of Inspection __________

HOSPITAL/CLINIC/LABORATORY CHECKLIST

1. Type of health care institution

Hospital Clinic Laboratory
Funeral Parlor others (please specify)_________
2. If hospital please check the classification.
Tertiary Secondary Primary Other_________
3. If clinic check the classification
Health Center Out Patient Dental clinic
Maternity and lying-in Medical Other_________
4. Permitting System
Generator ID No. __________________ Date issued _____________________
Permit to Transport No. _____________ Expiration Date __________________
ECC No.__________________________ Date issued _____________________
Discharge Permit No. _________________ Date issued _____________________
Stand-by Generator _________ kVa
Permit to Operate of Air Pollution Source No. ______________ Date Issued __________
Pollution Control Officer ____________________ DENR Accredition No. _____________
5. Presence of Health Care Waste Management Committee
Yes No Not applicable

6. Presence of Health Care Waste Management Plan?

Yes No Not applicable

7. Please check the waste management practices being implemented

Segregation composting recycling

Reuse recover pre-disposal treatment of waste
Color coding bags or containers according to the type of wastes
Periodic monitoring and evaluation of the waste generated
Material recovery facility (MRF) operation
Temporary waste depository operation
8. Types of health care waste being generated. Please indicate the volume in kilogram per
day.
Non – infectious wet waste/kitchen waste Volume _______ kg/day
Non – infectious dry wastes (papers, cartons, etc.) Volume _______ kg/day
 Pathological waste (Tissues, organs, body parts) Volume _______ kg/day
Radioactive waste (nuclear, medicine, radiology) Volume _______ kg/day

Chemical waste (spent chemicals/solvents, Volume _______ kg/day

chemotherapy waste, old x-ray films,
disinfectants and contaminated chemical
containers
Infectious wastes (spent cultures, stocks of Volume _______ kg/day
Infectious agents from laboratories, wastes
from surgery and autopsies on patients with
infectious diseases, wastes from infected
patients in isolation wards and dialysis section)

Sharps (needles, syringe, scalpels, saws, Volume _______ kg/day

blades, broken glasses, nails, etc.)

Pharmaceutical Waste (expired and spent Volume _______ kg/day

Pharmaceutical products and drugs

Pressurized containers (aerosol cans, gas tanks, etc) Volume _______ kg/day

Mixed health care waste Volume _______ kg/day

9. Please check the waste disposal system and facilities being used by the institution
Sanitary landfill controlled dumpsite small burial pit
Encapsulation safe burial on hospital premises
Autoclave system microwave treatment pyrolisis treatment
Waste water treatment facility Material Recovery Facility composting facility
Private treater and transporter. Pls. specify the company name and address.
_________________________
_________________________
Ask for a copy: 1. Manifest Form (latest)
2. Certificate of Treatment and Disposal (latest)
3. SMR (period covered October –Dec. 2014)

Inspected by:
_________________________ _____________________
_________________________ _____________________

Conformed by:
_________________________
_________________________