Appendix A - Survey Tools
ACADEMIC LABORATORY MERCURY MINIMALIZATION | SECURED DOCUMENT Academic Affairs Laboratory Safety Mercury Survey College of Pharmacy
Number: AALSSD 2-30-3500 CP-F01 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. Drug & Biologic Products- Thimerosal: Akorn Inc. AK Spore Ophthalmic Solution AK Spore HC Ophthalmic Combo Drops Fluoracaine Ophthalmic Solution AK Spore HC Otic Suspension Alcon Laboratories Profenal 1% Ophthalmic Solution Adsorbonac 2% Ophthalmic Solution Adsorbonac 5% Ophthalmic Solution Allergan America Ocufen Ophthalmic Solution Poly Pred Ophthalmic Suspension Allergan Inc. Blephamide SOP Ophthalmic Ointment Bleph-10 Ophthalmic Ointment 10% FML SOP Ophthalmic Ointment 0.1% Poly Pred Ophthalmic Suspension Altaire Pharmaceuticals Nasal Relief 12 Hour Spray American Assn. Retired Oxymetazoline Nasal Spray Persons American International Thimersol (bulk chemical) Chemical
Thimerosal USP 97% (bulk chemical) American Pharmaceutical 12 Hour nasal Solution Appletree Markets Long Lasting Nasal Spray Bausch & Lomb Flurbiprofen Sodium Ophthalmic Solution Neomycin & Polymyxin B Sulfates & Gramicidin Ophthalmic Solution Neomycin & Polymyxin B Sulfates & Hydrocortisone Otic Suspension Sulfacetamide Sodium & Prednisolone Sodium Phosphate Ophthalmic Solution 10%/.23% Bristol-Myers Squibb Fungizone Solution Fungizone Cream C.O. Truxton Inc. Bio-Cot Otic Suspension Decongest Nasal Spray Cheshire Pharmaceutical Otocort Otic Suspension Ocutricin Ophthalmic Solution Sulfapred Ophthalmic Solution CVS Nasal Spray Pump CVS Revco DS Inc. 12 Hour Decongestant Pump Nasal Spray Dolder Ltd. Thimerosal (bulk chemical) Dorex International Corp. Long Acting Nasal Spray Drug Guild Distributors Long Acting Nasal Spray Kolex LA DRX Pharmaceutical Blephamide Ophthalmic Ointment Cortisporin Ophthalmic Suspension Neomycin Polymyxin B Sulfates Hydrocortisone Ophthalmic Suspension Neomycin Polymyxin B Hydrocortisone Otic Suspension Neomycin Polymyxin B Gramicidin Ophthalmic Solution Vasocidin Ophthalmic Solution Colymycin S Otic Suspension Pediotic Otic Solution Dysers Sal Thimerosal (bulk chemical) Family Independent 12 Hour Nasal Decongestant Spray Pharmacy Long Acting Nasal Spray Farm Fresh Inc. Hemerrhoid Relief Ointment Fays Drug Services 12 Hour Nasal Spray Pump Federated Foods Long Acting Nasal Spray Fleming Companies 12 Hour Nasal Spray Foxmeyer Drug Co. Nasal Spray Pump Global Source Nasin Long Acting Nasal Spray Harco Drug Mercurochrome Aqueous Solution King Pharmaceuticals Cortisporin Ophthalmic Suspension Neosporin Ophthalmic Suspension Viroptic Ophthalmic Solution Neomycin Polymyxon B Sulfates Hydrocortisone Otic Suspension Pediotic Suspension Cortisporin Otic Suspension Kinray Oxymetazoline Nasal Spray Laboratori Derivati Adrenal Cortex Injection Leader 12 Hour Nasal Spray Nasal Pump Spray LS Raw Materials Ltd. Mercurochrome NF 12 100% (bulk chemical) Major Pharmaceuticals Sulfacetamide Sodium & Prednisolone Sodium Phosphate Ophthalmic Solution Cortomycin Otic Suspension Neocidin Ophthalmic Solution Martin Surgical Supply Testosterone Injection Suspension 50 mg Testosterone Injection Suspension 100 mg Mays Drug Stores Hemerrhoid Relief Ointment Medalist Laboratories Long Lasting Nasal Spray Pump Meyers Supply Inc. Long Acting Nasal Spray Navresso Long Acting Nasal Spray Omicron Quimica SA Thimerosal USP 97% (bulk chemical) Parade (Grocer’s Supply) Oxymetazoline Nasal Spray Parkedale Pharmaceuticals Coly-Mycin S Otic Suspension Pay N Save Corp. Decongestant Nasal Spray Pharmedix Bleph 10 Ophthalmic Solution 10% Viroptic Ophthalmic Solution 1% Blephamide Ophthalmic Ointment Triple Antibiotic Ophthalmic Solution Colymycin S Otic Solution Neo Poly with HC Otic Suspension Physicians Total Care Inc. Neomycin Polymyxin B Sulfates Hydrocortisone Ophthalmic Suspension Viroptic Ophthalmic Solution Cortisporin Ophthalmic Suspension Ocufen Ophthalmic Solution Vasocidin Ophthalmic Solution Ping On Ointment Co. Ltd. Ping On Topical Ointment Prime Natural Health 12 Hour Nasal Spray Primedics Laboratories Testosterone Injection Suspension 50 mg Publix Inc. Long Acting Nasal Spray Qualitest Pharmaceuticals Nasal Spray Solution Antibiotic HC Otic Suspension RDS Acquisition Corp. 12 Hour Nasal Spray Republic Drug Co. 12 Hour Nasal Spray Schering-Plough Animal Gentocin Durafilm Ophthalmic Solution (for dogs ony) Health Scrivner Inc. Hemorrhoid Relief Ointment Sight Pharmaceuticals Neomycin Polymyxin B Sulfates Hydrocortisone Otic Suspension Sulfacetamid Sodium & Prednisolone Sodium Phosphate Ophthalmic Solution Spectrum Quality Products Merbromin (bulk chemical) Thimerosal (bulk chemical) Super Laboratories Long Acting Nasal Spray Taro Laboratories Taro Nasal Decongestant Spray Teral Laboratories Oticin HC Otic Suspension Thames Pharmacal Co. 12 Hour Nasal Spray Thrifty Payless Inc. Nasal Spray Pump Formula Decongestant Nasal Spray Pump United Research Labs Antibiotic Ear Suspension Neomycin Polymyxin B Sulfates Gramicidin Ophthalmic Solution US Ophthalmics Fluorescein Sodium Ophthalmic Solution Sulf-10 Ophthalmic Solution Vasocidin Ophthalmic Solution Phenylephrine HC1 Ophthalmic Solution 10% USCO Logistics Procofen Ophthalmic Solution Profenal Ophthalmic Solution VEDCO Inc. Tribiotic Ophthalmic Solution Waldbaum Inc. Hemorrhoid Ointment Weeks and Leo Co. Inc. Long Acting Nasal Spray Solution Whitehall-Robins Dristan 12-Hour Nasal Spray The following are synonyms and trade names for Thimerosal: Aeroaid Merzonin sodium Curativ Merzonin, sodium salt Ethyl (2-mercaptobenzoato-S) mercury sodium Nosemack salt [(o-carboxyphenyl)thio] Ethyl mercury sodium Sodium ethylmercurithiosalicylate salt o-(Ethylmercurithio) benzoic acid sodium salt Mercurothiolate Elcide 75 Mertorgan Elicide Merfamin Estivin Septicol Ethylmercurithiosalicyclic acid, sodium salt SET Ethylmercurithiosalicylate sodium Sodium ethylmercuric thiosalicylate Ethylmercurithiosalicyclic sodium salt Sodium ethylmercurithiosalicylate Mercurothiolate Sodium merthiolate Mercurate(1-), {ethyl[o-mercaptobenzoato(2-)]-,} Sodium o-(ethylmercurithio) benzoate sodium
Mercurate(1-),{ethyl[2-mercaptobenzoato(2-)- Sodium salt of 2-(carboxyphenyl) thioethylmercury O,S]-,} sodium
Mercurochrome® Sodium 2-(ethylmercurithio) benzoate Thimerosal Mercural Thimerosal solution Thimerosalate Mercury, ethyl(hydrogen o-mercaptobenzoato)-, Thimerosal sodium salt
Mercury, ethyl(2-mercaptobenzoato-S)-sodium Thimerosal solution salt
Mercury {[(ocarboxyphenyl)thio]ethyl}-sodium Thimersalate salt Thiomerosal Merphol Thiomersalate Merseptyl (VAN) Thiomersalate Merthiolate® Thiomersal Merthiolate salt Thiomersalan Merthiolate sodium Vitasepto
List all formulated mercury (added products) including but not limited to: acids, alcohols, bleach (sodium hypochlorite), material used for cleaning, in maintenance, or for disinfection, and 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 Highoutput 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