Mercury Reduction Medical Facility Mercury Survey   Source: "Reducing Mercury Use in Health Care" Original document developed by Western Lake Superior Sanitary District.       This checklist is provided as a sample. A checklist can be useful tool to help medical facility staff identify sources of mercury in their workplace.

Type of Facility (hospital, clinic)	___________________________
Size of Facility (number of beds, number of patient visits)	___________________________
Contact Name	___________________________
Title	___________________________
Phone	___________________________

 
 

MERCURY SOURCES   Please indicate the following mercury sources located or used in your facility. ____ Fever thermometers (including home-care visits and those sent home with new borns) ____ Sphygmomanometers ____ Commercial manometer ____ Gastrointestinal diagnostic equipment ____ Feeding tubes   Chemicals ____ Zenker’s solution ____ Histological fixatives   Staining solution and preservatives ____ Mercury chloride ____ Mercury (II)oxide ____ Mercury(II) chloride ____ Mercury(II) sulfate ____ Mercury nitrate ____ Mercury iodide ____ other   Lamps ___ Fluorescent ____ Metal halid ____ High pressure sodium ____ Ultraviolet   Batteries ____ Mercuric oxide ____ Button batteries ____ Thermostats ____ Barometers ____ Switches(relay, tilt, silent) ____ Other possible mercury sources – please list here any other materials that should be a concern for mercury pollution.   Have you considered mercury-free alternatives for any of the products listed above? __ Yes __ No     FACILITY PRACTICES   Complete the following section on facility practices. Additional pages may be attached if needed.   Safety Practices   Is staff training provided on the health and environmental concerns of Mercury? __ Yes __No Is staff training provided on mercury spill prevention or management? __Yes __No If yes, indicate the departments that have this training and the frequency. _______________ _____________________________________________________________________ Is there a mercury spill clean-up tool kit on site? __Yes __No Have there been any mercury spills within the last ten years? __Yes __No If yes, indicate the source of the spill(s) and the clean-up method. ____________________ _____________________________________________________________________     Purchasing Practices   Does your facility have a policy on purchasing mercury-containing products? __Yes __No If yes, please attach policy.__________________________________________________ ______________________________________________________________________ Does your purchasing department currently require a disclosure by your vendors of mercury concentrations in chemicals/reagents? __Yes __No     Disposal Practices   What is the current procedure for disposal of medical waste? __Autoclave __Incineration __Other Have your sewer drain traps or catch basins been cleaned to remove mercury? __Yes __No If yes, list the area of the facility and dates.______________________________________ ______________________________________________________________________ Was mercury discovered? __Yes __No Are any mercury products in your facility currently recycled? __Yes __No Are there other facility practices that you think should be a concern for mercury pollution? List here: ______________________________________________________________________ ______________________________________________________________________

Mercury Reduction   R E G I S T E R     G L O S S A R Y     F E E D B A C K     S I T E  M A P     H O M E

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