Ambulatory Medical Waste Management Program (non-licensed only)

Purpose

This Medical Waste Management Program is managed by the UCLA Health Office of Environmental Health & Safety Ambulatory Safety Division.  The program provides the non-hospital licensed clinics with the tools and resources needed to ensure compliance with local, state and federal regulations.

Scope

The Ambulatory Medical Waste Management Program applies to all clinics that are not under the hospital's license. Clinics whose medical waste is serviced by UCLA Health Environmental Services (EVS) are excluded from this program (e.g. clinics in 200 Medical Plaza, 1223 MOB, etc.)

Services

The Ambulatory Safety Division is available upon request to consult with clinics on their medical waste protocols and provide In-Service Training for managers and staff on site specific needs.

Guidance

Below are the steps each applicable clinic manager or designee should follow to help manage your site specific Medical Waste Program and ensure compliance with local, state and federal regulations.

Step 1: Create a computer folder on your shared drive and name it "Medical Waste Management"

Step 2: Create a 3-ring binder and label it “Medical Waste Management/Stericycle”. This binder will be used to maintain copies of your Stericycle account information and receipts following a waste pick up, Medical Waste Management Plan, Medical Waste Generator Permit and other relevant materials for future reference.

Step 3: Click the link to Read & Complete the Medical Waste Management Plan template.
As a generator of medical waste, you must ensure that you have a Medical Waste Management Plan specific to your location that is compliant with local, state and federal regulations.

When the Medical Waste Management Plan is complete:

1. Name the file "Medical Waste Management Plan_MM-YYYY" & save it in the "Medical Waste Management" folder you created in step 1.
2. Print a hard copy and keep it in the “Medical Waste Management/Stericycle” binder you created in step 2.
3. Email a copy of the Medical Waste Management Plan for review and approval to: FPGSafety@mednet.ucla.edu

Step 4: Complete the Medical Waste Site-Inspection Checklist
Use this checklist to verify whether your location is compliant with local, state and federal regulations. The initial completion of this checklist should occur within 30 days of implementing the Medical Waste Management Plan and as needed thereafter. Copies should be maintained in your electronic “Medical Waste Management” folder.*

*If you have any areas of non-compliance contact Ambulatory Safety Division for assistance.

Optional: Medical Waste In-Service Training for staff is available upon request.

NOTE: If you have any RCRA Hazardous Waste products in need of disposal contact Ambulatory Safety for assistance.

If you need assistance implementing your Medical Waste Management Program or you receive a letter/notice from the California Department of Public Health (CDPH) or other regulatory enforcement agency regarding your Medical Waste Generator status contact the Ambulatory Safety email

Resources

• Getting your small or large waste generator permit (only when serviced by Stericycle and not hospital EVS) - CDPH form 8550
  • fill out form-you can follow this guide-and send a check with the amount for either small quantity generator or large quantity generator fee amount.  
• Medical Waste Management Plan Template
• Medical Waste Site-Inspection Checklist
• Medical Waste Management Containment Guide
• Medical Waste Accumulation Room Door Signage
• Biohazard Labels - Vendor Option: Grainger Mfr. Model #18766LS
• Pharmaceutical Waste Container Labels Template - Avery Label #5160
  
  • Place label on lid and each lateral side of blue/white non-hazardous pharm waste containers.
• Trace Chemo Waste Container Labels Template - Avery Label #5160
  
  • Place label on lid and each lateral side of yellow/white trace chemo
• Obtaining an EPA ID for Hazardous Waste- DTSC form 1358
  • Guide for filling out form

Questions?

Contact the UCLA Health Ambulatory Safety Division at: FPGSafety@mednet.ucla.edu