This
form
is
to
help
you
establish
your
facility's
H2E
goals
and
track
progress.
H2E
will
not
request
you
to
submit
these
forms
in
2002;
however,
we
will
be
collecting
the
forms
in
2003.
We
are
interested
in
your
comments!
Please
submit
any
comments
to
the
address
at
the
end
of
this
form.

SECTION
1:
CONTACT
INFORMATION
Facility/
System
Name:
________________________________________________
Date:__________________________

Contact
Name:
__________________________________________
Title:_______________________________________

Address:
______________________________________________________________________________________________________

City:
_____________________________________
State:
______________________________
Zip:
__________________

Phone:
______________________________
Fax:
______________________________
E­
mail:______________________

The
information
contained
on
this
form
is
for
the
year
________________

SECTION
2:
FACILITY
INFORMATION
SECTION
3:
FACILITY
WASTE
ASSESSMENT
SUMMARY
Annual
Facility
Assessment
Summary
and
Goals
Form
Facility
Type
Total
In­
Patient/
Hospital
Adjusted
Patient
Days*:

Beds:

Staff:

Ambulatory
Care/
Outpatient
Clinics
Outpatient
Visits:

Staff:

General
Administrative
Staff:

Long
Term
Care
Beds:

Staff:

*
Adjusted
Patient
Days
=
Total
Patient
Days
x
(
Total
Patient
Revenue
(
Inpatient+
Outpatient)
/
Inpatient
Revenue)

Establish
a
baseline.
The
first
step
to
measuring
annual
progress
at
your
facility
is
to
conduct
a
baseline
assessment.
The
H2E
Self­
Assessment
Guide,
available
at
<
www.
h2e­
online.
org>,
can
help
you
in
this
process.
For
questions
or
assistance,
please
contact
us
at
800
727­
4179.
You
are
welcome
to
use
other
waste
assessment
tools
and/
or
consultants.
For
H2E
tracking
purposes,
your
baseline
year
should
be
from
1998
or
later.

Record
annual
progress.
Use
this
same
form
to
track
your
facility's
annual
waste
data.
This
form
will
also
help
you
identify
and
track
goals
for
your
facility
(
see
Section
6).

Waste
Management
Category
Tons
/
Year
Percent
of
Total
Waste
Annual
Costs
Solid
Waste
Recycling/
Reuse
Regulated
Medical
Waste
Hazardous
Waste
Total
100
SECTION
4:
MERCURY
ASSESSMENT
For
information
on
how
to
evaluate
mercury
use
and
implement
activities
to
eliminate
mercury
from
your
facility's
waste
stream,
download
the
H2E
Self­
Assessment
Guide
at
<
www.
h2e­
online.
org>.
See
Sections
5A
and
B
in
the
guide.

Is
your
facility
virtually
mercury
free?

Yes

No
Has
your
facility:

 
Conducted
a
facility
inventory
of
mercury
containing
devices
and
chemicals?

Yes

No
 
Implemented
a
mercury
purchasing
policy?

Yes

No
 
Eliminated
mercury­
containing
patient
care
devices?

Yes

No
(
e.
g.,
thermometers,
sphygmomanometers,
bougies,
dilators)

Please
highlight
efforts
to
eliminate
mercury
from
your
facility
to
date.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

SECTION
5:
ENVIRONMENTAL
POLICIES
Please
indicate
if
your
facility
has
any
of
the
following
policies
by
marking
your
response.
If
no,
you
might
consider
implementing
these
policies
for
your
H2E
program.

Facility
Environmental
Commitment
Statement

Yes

No
Comprehensive
Waste
Management

Yes

No
Mercury
Management/
Elimination

Yes

No
Environmentally
Preferable
Purchasing

Yes

No
SECTION
6:
H2E
GOALS
Please
list
your
facility's
goals
below
and
describe
any
activities,
including
source
reduction,
mercury
elimination,
recycling,
reuse,
donation,
and
other
efforts,
that
your
facility
will
implement
to
achieve
these
goals.
For
more
information,
consult
"
How
to
Develop
Your
H2E
Goals"
on
the
H2E
Web
site
located
at
<
www.
h2e­
online.
org>.

Goal
1:_______________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Goal
2:_______________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Goal
3:_______________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Goal
4:_______________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

Goal
5:_______________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

When
notified,
please
mail
or
fax
this
form
to:

Hospitals
for
a
Healthy
Environment

1755
S
Street
NW,
Suite
6B

Washington,
DC
20009
Phone:
800­
727­
4179

Fax:
202­
234­
9121
