Dental Office Best Management Practices Survey - City Of Salem

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FOR OFFICE USE ONLY
RECORD_____________
ENTERED____________
Dental Office Best Management Practices Survey
Business Name
Date__________________
Physical Address
Zipcode________________
Mailing Address if different_______________________________________________________
Phone
Fax
E-mail___________________________
Names of other dentists in your practice_____________________________________________
_____________________________________________________________________________
Radiographic Materials
1. What type of X-ray technology is used at this location?
G
Traditional Radiography
G
Electronic Imaging
2. How much fixer is used per month? ______________________
3. How does this office dispose of spent fixer?
G
Dumped down the drain to the sanitary sewer
G
Metal replacement canister, Provider Name___________________________________
G
Stored on-site for future disposal
G
Recycled, Provider Name__________________________________________________
4. How much X-ray film is purchased quarterly? ________________________
5. How does this office dispose of X-ray lead foil?
G
Disposed of in the trash
G
Hazardous waste, Provider Name___________________________________________
G
Stored on-site for future disposal
G
Returned to vendor, Vendor Name__________________________________________
G
Disposed of as a biohazard material
G
Recycled, Provider Name__________________________________________________
Survey continues on the reverse side

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Parent category: Medical
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