General Information
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Clinical Area where disinfection is performed:

Room Number where glutaraldehyde is used:

Are patients examined (or undergo procedures) in this room?

Name of employee(s) who performs disinfection activities (Optional)

Commercial product name (and % glutaraldehyde, if known):
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Health Effects
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Noticeable odor when using this product?: Yes ____ No _____

If you answered "Yes" to #4, is the Odor Strong ____ or Weak ____ ?

Any symptoms or health complaints associated with working with this product?      Yes____ No ____ If Yes, please describe:
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Please describe the following procedures:
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Name of device(s) disinfected in this area:

What type of container is used for the glutaraldehyde solution? (Check box that       applies to your situation)

_____ Open Bin (describe Bin type or brand if available)

_____ Open Bin with Lid (describe Bin type or brand if available)

Are Lids Kept on _____ most of the time?  _____ some of the time?

_____ Enclosed System (list name brand and model if available)
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Is this device routinely pre-cleaned before it enters the glutaraldehyde solution?
(If yes, please list the name of the pre-cleaning solution utilized). __________________________________________________f

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Length of time device is soaked in glutaraldehyde solution:

Method of retrieving device from glutaraldehyde solution (e.g. remove with gloved hand , tongs, etc):
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Type of gloves worn, if any (brand and material):

Type of protective gear worn, if any (e.g. goggles, face shield, apron):

How often this procedure is performed (specify daily, weekly or other):

Where do you dispose of the spent glutaraldehyde solution?

How do you dispose of the glutaraldehyde?

How much glutaraldehyde is disposed of per week? Per month?

How do you refill the soaking bin or system with glutaraldehyde? (check box)

_____ pour from bottle
_____ pour from bottle with funnel
_____ pour with special glutaraldehyde spout
_____ other (please describe): ________________________________

THANK YOU!