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Amalgam Practices Reporting Form

  1. Provide the full name and contact information of the person completing this form and for the business being assessed.

  2. 1. Does this business use amalgam in procedures, or remove teeth amalgam?*

  3. 2.A. Does this business use only pre-capsulated amalgams, and bulk mercury is recycled.*

  4. 3.A. Is all amalgam captured in filters and traps recycled?*

  5. 4.A. Are all disposable amalgam capsules recycled?*

  6. 5.A. Is all non-contact amalgam (scrap) salvaged, sorted and recycled?*

  7. 6.A. Is all contact amalgam (used) salvaged, sorted and recycled?*

  8. 7.A. Are only non-oxidizing, non-chlorine disinfectants and neutral line cleaners used on premises?*

  9. 8.A. Are all extracted teeth containing amalgam recycled?*

  10. 9.A. Is all amalgam waste recycled through a certified recycler, or vendor/ manufacturer?*

  11. 10. Is this business subject to the Resource Conservation and Recovery Act (RCRA)?*

  12. 11. Is this business classified as a Very Small Quantity Generator (VSQG)?*

  13. 12.A. Does this business operate and maintain an International Organization of Standards (ISO) 11143 approved amalgam separator? *

  14. I hereby declare that I am properly qualified and authorized to complete this form on behalf of the aforementioned business, and that the information contained herein is true and correct to the best of my knowledge and belief. *

  15. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  16. Leave This Blank:

  17. This field is not part of the form submission.