Appendix 3 - Model Agreement for Non-Pharmacy Sharps Transport and Disposal
Model Agreement for Non-Pharmacy Sharps Transport and Disposal
Also available as a PDF 76KB for Providers to print and use
___(insert name of pharmacy)__ in cooperation with ___(name all partners, article 28 or permitted haulers)__ agree to participate in a safe sharps collection project that includes collection kiosks or containers located at the following sites:
- ___(insert names and addresses of all sites)___
- __________________________________
- __________________________________
It is agreed that ___(insert pharmacy name)___ and ___(sharps transporting organization)___ agree to the following activities:
___(insert pharmacy name)___ will locate collection receptacle, "kiosk" or "drop box" on-site at ___(insert address)___.
This collection receptacle, "kiosk" or "drop box" will be secured such that only pharmacy employees, transporting agency employees or other appropriately trained persons have access to the used sharps contained within the unit.
___(insert name of transporting organization)___ agrees to open and close the collection receptacle, "kiosk" or "drop box" at agreed up on times for the purpose of removing and transporting collected sharps in a sealed secondary container for purposes of ultimate disposal.
___(insert name)___ is responsible for replacing the internal collection tub as needed;
___(insert name)___ is responsible for cleaning the collection receptacle, "kiosk" or "drop box" at least once a month, in accordance with OSHA standards; more frequently if indicated or if spillage or other incident occurs.
___(insert name)___ agrees to monitor the collection receptacle, "kiosk" or "drop box" periodically and to contact the ___(insert name of transporting organization)___ regarding increases in usage and the potential need for more frequent pick-up or cleaning.
The undersigned agrees on the activities stated above:
Signature_________________________________
Date____/______/________