Appendix A - Survey Tools ACADEMIC LABORATORY MERCURY MINIMALIZATION | SECURED DOCUMENT Academic Affairs Laboratory Safety Mercury Survey College of Art & Science
Number: AALSSD-2-30-3500-CAS-FF01 Author: Anne Hawkins Effective Date: Revision Date: Accepted/ Issued:
Name of individual filling out survey:
Title:
Phone: Please indicate if the following mercury sources are located or used in your Department I. Equipment: Barometers Batteries Centrifuges Fever Thermometers Hood Manometer Sphygmomanometers Thermostats Other
II. Chemicals/Staining Solutions & Preservatives:
Mercury iodide Mercury (I) Bromide Mercury (I) Carbonate Mercury (I) Chloride Mercury (I) Chromate Mercury (I) Dichromate Mercury (I) Nitrate Mercury (I) Nitrate Mercury (I) Oxide Mercury (I) Sulfate Mercury (I) Sulfide Mercury (II) Acetate Mercury (II) Ammonium Thoocyanate Mercury (II) Bromate Mercury (II) Bromide Mercury (II) Carbonate Mercury (II) Chlorate Mercury (II) Chloride Mercury (II) Chromate Mercury (II) Dichromate Mercury (II) Hydrogen Carbonate Mercury (II) Hydroxide Mercury (II) Iodate Mercury (II) Nitrate Mercury (II) Nitrate Monohydrate Mercury (II) Nitrite Mercury (II) Oxide Mercury (II) Nitride Mercury (II) Phosphate Mercury (II) Sulfate Mercury (II) Sulfide Mercury (II) Thiosulfate Commercial Chemical Products Acetate Acetic acid Alum Ammonium reagent/Stone analysis kit Antibody test kits Antigens Buffers Chloride Diluents Ethanol Fixatives Immunoelectrophoresis reagents Immunofixationphoresis reagents: Immu-sal Potassium hydroxide Shigella bacteria Sodium hypochlorite Sulfuric acid Thimerosal T Tracer kits Urine analysis reagents Other
III. List all formulated mercury (added products) including but not limited to: acids, alcohols, bleach (sodium hypochlorite), material used for cleaning, in maintenance, for disinfection, reagents:
IV. Facility Related Systems/ Equipment & Supplies
Analytical Instruments Commercial Cleaning Agents Bleach Detergents Scouring powders Soaps Lamps Bilirubin blue Cold cathode Fluorescent General purpose Germicidal High output Hot cathode Mercury vapor ultraviolet spectral Metal halide high pressure sodium vapor Neon (all colors except red, orange, and pink Slimline
V. Please list any other possible sources of mercury or any other materials that could be a concern for mercury pollution.
VI. Have you considered or adopted mercury free alternatives for any of the products listed above? Please explain.
Please complete the following section on practices at your facility:
Does your facility have a policy on purchasing mercury containing products? Yes No If yes, please attach a copy of the policy. Do you currently require disclosure by vendors of mercury concentrations in solutions? Yes No What is the current procedure for disposal of medical waste? Autoclave Incineration Other