©EPA
ynited
Environmental Protection
Agency Mew England
1 Congress Street, Suite 1100 SPP
Boston, MA 02114-2023
EPA901-F-04001
April
EPA New England- Hospital Environmental Assessment Template
An environmental compliance and pollution prevention tool
Introduction
This tool was developed for an Office of Environmental Compliance and Assistance (OECA) grant which was given to the University
of New Hampshire Pollution Prevention Program. The tool was modified into three state specific tools for CT, RI and NH. The
interns collected and compiled information from a total of 25 hospitals in the three states. A copy of the final report can be found at
http://www.unh.edu/p2/nhppp/i2003.html. This tool is not all-inclusive and it does not include all Federal hospital requirements or
preferable practices. If you are a VA there are additional requirements that will apply to you that are not covered in this template. In
addition, you should also always check with your state for any additional state requirements. If you would like a word version of this
document to customize for your state or EPA Region, please email Janet Bowen of EPA Region I at Bowen. Janet@epa .gov or call her
directly at (617) 918-1795.
Section I: General Facility
1.1 Number of Hospital Beds: <75
1.2 What state are you located in?
75-200
>200
1.3 What department(s) are responsible for environmental compliance at your hospital? (Check all that apply)
Health and Safety Maintenance/Facility Industrial Hygienist
Environmental Nursing Other (Specify)
1.4 Has your hospital used EPA technical resources? (Check all that apply)
_ Accessed H2E website
_ Participate H2E teleconferences
_H2E fact sheets
_ 3/21/01 Hospital workshop in CT
_ Accessed Region I website
SPCC Amendment fact sheet
Participate on H2E Listserv Telephone assistance from EPA
Participate Energy Star internet training Information from EPA at event
H2E Assessment Accessed EPA website
EPA presentation EnergyStar Benchmarking information
11/6/02 SPCC training in CT Mercury Challenge Partners directory
EPCRA fact sheet Other (Specify)
1.5 What changes or actions (if any) have you made as a result of EPA/H2E assistance? (Check all that apply)
_Filed notification
Obtained permit
_Provided employee training
_Submitted documentation to EPA/State
_Adopted formal purchasing policy
_Became H2E Partner
Jnventoried mercury use/equipment
_Benchmarked/increase energy efficiency
_Minimized infectious waste
_Came into compliance
Jmproved/evaluated water
efficiency
_Reduced/replaced mercury items
Jnstituted/increased recycling/reuse
_Other (Specify)
Section II: Compliance Self Assessment
1.0 Resource Conservation and Recovery Act (RCRA) (40 CFR 261, 262, 265)
1.1
1.2
1.3
1.4
1.5
What is your hospital's generator status? (Please check)
No Hazardous Waste CESQG1 SQG2 LOG3 Don't Know (DK)
Does your hospital have an EPA hazardous waste generator number?
Storage
Is all hazardous waste stored in either a satellite accumulation area and/or a separate hazardous waste
storage area?
Are the satellite accumulation areas clearly identified?
Are all hazardous waste containers kept closed except when filling or adding waste?
Y
N
Some
DK
NA
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1.0 Resource Conservation and Recovery Act (RCRA) (40 CFR 261, 262, 265)
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
Are all hazardous waste containers in good condition?
Is there a secondary containment system in the hazardous waste storage area?
Does the storage area have an impervious surface and no floor drain?
Does your hospital maintain emergency and safety equipment within the hazardous waste storage
area? (spill kits, eye wash, personal protective equipment (PPE), etc.)
Does your hazardous waste storage area have a communication device? (telephone, alarm, etc.)
Labeling
Are hazardous wastes stored in labeled containers with:
the words "Hazardous Waste"
the name of waste
the EPA waste code
the date container was placed in storage'?
Inspections
Is the hazardous waste storage area inspected weekly for signs of spills or container deterioration?
Are the inspections documented?
Is there a hazardous waste determination on file for all wastes?
Contingency Plan
Is there an updated RCRA Contingency Plan including accurate phone numbers?
Was a copy of the RCRA Contingency Plan sent to the local fire department?
Training
Do employees receive hazardous waste management training related to their job duties?
Are these training records maintained?
Manifests
Does the hospital maintain its manifests for at least three years?
Does the hospital maintain Land Disposal Restriction notices with the manifests that they are
providing the Notice for?
Y
N
Some
DK
NA
2.0 Universal Waste4 (40 CFR 273)
2.1
2.2
2.3
2.4
Does your hospital handle Universal Waste separately from your other hazardous waste?
Tip: For more information on Universal Waste visit
http://www.epa.gov/epaoswer/hazwaste/id/univwast.htm
If yes to 2. 1, does your hospital label its Universal Waste and specify type (e.g., lamps, batteries)?
If yes to 2. 1, does your hospital store Universal Waste in appropriate containers that prevent releases
to the environment?
If yes to 2. 1, does your hospital have a system to document the length of time that the Universal Waste
has been accumulating?
Y
N
DK
NA
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3.0 Spill Prevention Control Countermeasure Plans (SPCC) (40 CFR 112)
3.1
3.2
3.3
3.4
Is oil of any kind stored above ground in containers or equipment that have a capacity of 55 gallons or
greater and a total aggregate capacity of over 1,320 gallons?
Tip: For more information visit EPA 's Oil Program website at http://www.epa.pov/oilspill/index.htm
Does your hospital store oil below ground in any size tank (s) with a total aggregate volume over
42,000 gallons not including Underground Storage Tanks regulated under 40 CFR 280 and 281?
(Note: USTs containing heating fuels for on-site heating purposes are exempted from 40 CFR 280 and
281)
Does your hospital have a Spill Prevention, Control Countermeasure plan (SPCC)?
If yes to 3.3, is it certified by a licensed Professional Engineer?
Y
N
DK
NA
4.0 Integrated Contingency Plan ("One Plan")
4.1
Has your hospital consolidated your various planning requirements into an Integrated Contingency
Plan ("One Plan") which encompasses various planning requirements including but not limited to
SPCC, RCRA Contingency Plan, OSHA HAZWOPER, OSHA Chemical Hygiene Plan, etc.
Y
N
DK
NA
5.0 Underground Storage Tanks (UST) (40 CFR 280 & 281)
5.1
5.2
5.3
5.4
5.5
Does your hospital store motor fuels, waste oils and/or hazardous substances in USTs? (Note: USTs
containing heating fuels for on-site heating purposes are exempted from RCRA UST.)
If yes to 5.1, are USTs registered with the State?
If yes to 5.1, are records available for showing registration?
If yes to 5.1, is there some form of leak detection in use for UST system's tank and associated piping?
If yes to 5.1, are there records showing monthly leak detection along with yearly UST system tightness
test?
Tip: Use EPA 's Basic Checklist for USTs found at http://www.epa.sov/swerustl/cmplastc/cheklist.htm
as a helpful, comprehensive tool to identify compliance lapses
Y
N
DK
NA
6.0 Community Right to Know SARA Title III - EPCRA (Sections 302-304, 311and 312)
6.1
6.2
6.3
6.4
Does the hospital have on-site, at any time during the calendar year, a listed Extremely Hazardous
Substance (EHS) in an amount over the threshold reporting quantity?
Tip: Find this list at http://vosemite.epa.sov/oswer/ceppoehs.nsf/EHS Profile? openform
If yes to 6. 1, has your hospital submitted a notification letter identifying the EHS and facility
emergency coordinator to the Local Emergency Planning Committee (LEPC)/State Emergency
Response Committee (SERC)?
Does the hospital have on-site at any time during the calendar year 10,0001bs of any product/material
requiring a Material Safety Data Sheet (MSDS)?
If yes to 6. 1 or 6.3, have Tier II chemical inventory forms (Tier 2 Submit for electronic submissions)
been filed annually with the local fire department, LEPC and SERC?
Tip: For electronic Tier II Submit go to
http://vosemite.epa.sov/oswer/CeppoWeb. nsf/content/tier2.htm#t2 forms
Y
N
DK
NA
7.0 Clean Air Act (CAA)
7.1
7.2
7.4
Does your hospital have a Title V operating permit?
If no to 7. 1, does your hospital have a State air permit?
Hospital/Medical/Infectious Waste Incinerators - 40 CFR Part 62 Subpart HHH
Does your hospital operate a medical waste incinerator on-site?
Y
N
DK
NA
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7.0 Clean Air Act (CAA)
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
7.13
7.14
7.15
7.16
7.17
7.18
Tip: For more information visit EPA 'sAir Toxic website,
http://www.epa.sov/ttn/atw/129/hmiwi/rihmiwi.html
If yes to 7.4, has EPA/ State been notified and the incinerator tested?
New Source Performance Standards - 40 CFR Part 60
Does your hospital have boilers constructed (manufactured) or modified after June 9, 1989 with heat
input between 10-100 MMBTU/hr or larger?
If yes to 7.6, did your hospital notify EPA and/or the State that you are subject to the New Source
Performance Standard (NSPS)?
Chlorofluorocarbon (CFC)
Does your hospital use a certified technician to service your refrigeration units with freon?
If your hospital uses in-house certified technicians, is your recovery /recycling equipment registered
with EPA?
Are annual CFC leak rate records and maintenance and repair records maintained for the refrigeration
and air conditioning system having over 50 Ibs of CFC normal refrigerant charge for a period of three
years?
Mobile Sources
Does your hospital have vehicle gasoline dispensing units on-site?
Specify annual throughput gal/yr
If yes to 7.11, are these units equipped with Stage 2 vapor recovery equipment?
Does your hospital prohibit hospital operated vehicles from idling?
Asbestos - 40 CFR Part 61
Has your hospital undergone any demolition/renovation within the last 18 months?
Tip: For more information asbestos, visit http://www.epa.gov/asbestosl
Has the hospital removed any asbestos from any facility components within the last 18 months?
If yes to either 7. 14 or 7. 15, was notification for the project provided to your State asbestos regulatory
agency?
If yes to 7. 15 and 7.16, was the area where the renovation/demolition occurred "thoroughly inspected"
for the presence of asbestos prior to commencement of the renovation/demolition activity?
Other
If you have a helicopter landing site, is exhaust prevented from entering the hospital?
Y
N
DK
NA
8.0 Federal Insecticide, Fungicide & Rodenticide Act (FIFRA)
8.1
8.2
8.3
8.4
8.5
Does your hospital mix/blend your own pesticides? (Pesticides include: disinfectants, sterilants, germicides,
algicides, virucides, swimming pool compounds, insecticides, fungicides, herbicides, etc.)
If your hospital uses your own janitorial employees to apply disinfectants and other pesticides, do you
offer/provide training as to the proper use of pesticides?
Does your hospital use any "Restricted Use" pesticides? (Note: Refer to the label)
If yes to 8.3, is the pesticide applied by a certified applicator or under direct supervision of a certified
applicator?
Are your hospital pest control operators licensed/certified by the state to apply pesticides?
Y
N
DK
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9.0 Clean Water Act (CWA)
9.1
9.2
9.3
Have all the wastewater discharges been identified and evaluated to determine whether they are being properly
managed? (Note: If the hospital discharges wastewater into a municipal sewer system you should check with
local publicly owned treatment works (POTW) for regulatory requirements.)
Is your hospital's wastewater directly discharged into surface water or groundwater?
If yes to 9.2, does your hospital have a National Pollutant Discharge Elimination System (NPDES) permit?
Y
N
DK
10.0 Toxic Substances Control Act (TSCA) (40 CFR 761) - Polychlorinated Biphenyl (PCB)
10.1
10.2
10.3
Does the hospital have any PCB -containing electrical equipment on-site?
If yes to 10.1, is the PCB -containing equipment properly identified?
If yes to 10.1, does your hospital inspect PCB -containing equipment regularly for leaks and keep records of
the inspections?
Y
N
DK
11.0 Lead Paint
11.1
11.2
11.3
11.4
Has your hospital sold or leased housing built before 1978?
If yes to 1 1 . 1 , did your hospital disclose potential and known lead-based paint and lead-based paint
hazardous?
If yes to 1 1 . 1 , did your hospital give buyers/renters the pamphlet titled "Protect Your Family from
Lead in Your Home" .
If yes to 1 1.2, are disclosures documented and the records kept for three years?
Y
N
DK
NA
Section III: Pollution Prevention
This section includes additional voluntary actions your facility can consider that may reduce environmental
liability, waste disposal costs, and worker exposure.
Tip: H2E or Hospitals for a Healthy Environment is national voluntary program, which has set goals for mercury toxics elimination and
solid waste reductions specifically for the healthcare industry. This program provides technical support and recognition for the industry.
Read more about H2E or join as an H2E partner by reading more at http://www.h2e-online.org/programs/partner/p_become.htm
1.0 Resource Conservation and Recovery Act (RCRA) (40 CFR 261, 262, 265)
1.1
1.2
1.3
1.4
1.5
1.6
1.7
Have you conducted a mercury audit of your hospital, including an inventory of all mercury
devices/sources?
Tip: Can you virtually eliminate mercury at your facility? Find out how at http://www.h2e-
online. ors/tools/mercury.htm
Have you replaced mercury thermometers (If yes, specify alternatives in the notes section)
in lab?
hospital patients?
in dispensing to outpatients including newborns?
Have you replaced mercury blood pressure units? If yes, specify alternative
Have you replaced other mercury containing cantor tubes, dilators, etc?
Have you identified which lab chemicals you use that contain mercury?
Have you replaced lab chemicals containing mercury?
Do you still purchase any equipment containing mercury?
Y
N
Some
DK
NA
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2.0 Solid Waste
Tip: For more information on Waste Reduction visit http://www.h2e-online.org/tools/waste.htm
2.1 Do you donate/compost any of the following (Check all that apply)?
_Food scrap/plate waste
_Landscape waste
Edible food
Medical device/equipment
_ Office equipment
Linen
2.2 Do you recycle any of the following materials? (Check all that apply)
Paper, white
Paper, color
Cardboard
Newspaper
Boxboard
Batteries
_ Nickel cadmium
_ Alkaline
_ Mercury
Lead acid
JTyvek
_Mattresses
Lead aprons
Plastics
#1 PET
#2 HOPE
#3 PVC
#4 LDPE
#5 Polyproplene
#6 PS
_Toner cartridges
_Ink jet cartridges
_Printer ribbons
_Computers
_Ice packs/coolers
_Fluorescent lamps
_Scrap metal
_Motor oil Expired Pharmaceuticals (reverse
_ Construction/demolition waste distribution)
_Other (Please specify)
_Xray films
_Silver recovery
_Solvents/fixers
_Foam peanuts
_Shrink wrap
_Mercury
_Sharps
_Wood
_Pallets
_Cooking oil
_Glass
_Steel cans
_Aluminum cans
Grass/leaves
2.3 Does your hospital reuse any of the following materials?
If you do not reuse enter 0; otherwise specify either < 50%, 50%, >50% or 100%. Write DK if you do not know andNA if not applicable.
Dietary
Dishware, patient
Dishware, employee
Glassware
Cutlery
Baking pans
Metal trays
Other
Reusable
(%)
Patient care
Bath basins
Mattress overlays
Water pitchers
Bed pans
Urinals
Pillows
Towels
Underpads (Chux)
Exam gowns
Linens
Other
Reusable
(%)
Surgery
Instrument pans
Splash basins
Medicine cups
Gowns
Towels
Drapes
Other
Reusable
(%)
Equipment
Ventilator tubing
Ambu bags
Pulse oximeters
Suture removal kit
Vaginal speculums
Other
Reusable
(%)
2.4 How much solid waste does your hospital generate per year (tons/year)?
2.5 How many tons/year did your hospital recycle? for calendar year
2.6 What percentage of your hospital's waste is medical red bag waste?
for calendar year
2.7 How does your hospital dispose of your medical red bag waste? (Please check)
incinerate (offsite) incinerate (onsite) autoclave (offsite) autoclave (onsite)
Other(specify)
% for calendar year_
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3.0 Purchasing
Tip: To read more about green purchasing visit http://www.h2e-online.org/tools/grnpurch/epp.hlm
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
Has your hospital instituted purchasing policies in any of the following areas? (Check all that apply)
"Green" Product Low VOC products PVC products and DEHP products
EnergyStar products Latex Specifying recycled content in products
Less toxic materials Mercury Other (Specify)
Has your hospital called upon vendors and your Group Purchasing Organization (GPO) to identify and
develop alternatives for harmful and/or wasteful products and materials?
Has your hospital worked with suppliers to minimize wasteful packaging?
Does your hospital receive supplies in reusable shipping containers?
Does your hospital use office paper with at least 30% recycled content?
Has your hospital evaluated alternatives to Polyvinyl Chloride (PVC) and DEHP containing products?
Does your hospital purchase non-toxic/less toxic alternatives for janitorial chemicals?
Do you use Ethylene Oxide at your hospital?
If yes to 3.8, have you evaluated alternatives?
Does your hospital have a central system in place for tracking and quantifying the amount of chemicals
purchased, dispensed and disposed of?
Does your hospital track the quantity or amount of green products and services used?
Y
N
DK
4.0 Energy/Water Conservation
Tip: To view EnergyStar information for Healthcare visit http://208.254. 22. 6/index.cfm?c=healthcare. bus healthcare
4.1
4.2
4.3
4.4
4.5
4.6
4.7
Have you created a baseline of energy performance for your hospital using the EPA's benchmarking tool?
Tip: To view the EnergyStar hospital benchmarking tool visit
http://208. 254. 22. 6/index. cfm ?c=eligibility. bus_portfoliomanager eligibility hospitals
Has your hospital done an energy management review within the last 3 years?
Has your hospital implemented within the last three years any of the following? (Check all that apply)
Heating/ventilation upgrades Control ventilation rates to minimum requirements
Air side cooling economizer cycle Energy efficient lighting upgrades
Programable thermostats Lighting occupancy sensors
Does your hospital purchase EnergyStar equipment? (Check all that apply)
Computers Fax machines Roofing Products
Monitors Printers Transformers
Copiers TVs Dishwashers
Scanners Exit signs Commercial refrigerator/freezers
Multifunction devices Water coolers Other (Specify)
Has your hospital assessed its water usage?
Tip to read about water conservation visit http://www.h2e-online.org/tools/water.htm
Have you implemented a water conservation program?
Does your hospital use any of the following water-efficient equipment or practices? (Check all that apply)
Low flow toilets Flow control mechanisms Regular inspection and repair of leaks
Low flow faucets Recirculating cooling water Landscaping/irrigation
Automatic faucet shut off Recirculate sterilizer water Low water Xray process
Low flow showerheads Kitchen Other (Specify)
Y
N
DK
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Section IV: General
4.1 Does your hospital have an Integrated Pest Management (IPM) program?
Yes
No
Don't Know
4.2 What environmental topics would you like more training in? (Check all that apply)
_General compliance
_RCRA - hazardous waste
JJniversal Waste
EPCRA
_CAA
SPCC
Solid waste recycling
_Energy Management Systems
Red bag waste reduction Energy conservation
_EPA Audit Program Resource management Green buildings
_Mercury Water conservation Environmental Management System
Integrated Pest Management Green purchasing Other (Specify)
4.3 What are your top three training needs?
Priority 1 Priority 2
Priority 3
4.4 Has your hospital taken any action not covered above to improve environmental performance? Please specify.
Notes on any questions above:
Question number
Comments
Conditionally Exempt Small Quantity Generator (CESQG) is a generator who generates less than 100 kg/month (about 220 Ibs/month) and never
accumulates more than 1000 kg (22001bs) or more. (Note2201bs is about half a 55 gallon drum)
Small Quantity Generator (SQG) is a generator who generates more than 100 kg/month (2201bs/month) but less than 1000 kg/month (2200 Ibs/month))
Large Quantity Generator (LQG) is a generator who generates more than 1000 kg/month (2200 Ibs/month) or generates 1 kg (2.2 Ibs) or more of an
cutely hazardous or severely toxic waste.
Federal definition includes batteries( eg, nickel cadmium), pesticides, lamps and thermostats
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