Health Care Environmental Purchasing Tool Environmental Purchasing Questionnaire

Health Care Environmental Purchasing Tool

Environmental Purchasing Questionnaire

Date:

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Company Name:

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Address:

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City:

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State/Province:

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Zip Code:

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Country:

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Name of Person Responding:

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Position/Title:

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Phone Number:

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Fax Number:

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E-mail Address:

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Product Name

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Product ID Number

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General Environmental Management Questions Yes = 0
No = 1
Don't Know = 1

1. Does your company have an Environmental Management System in place such as ISO 14000 or EMAS?
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2. Does your company regularly publish an environmental report that is available to the public?
.

3. Does your company regularly conduct internal environmental audits?
.

4. Is your company free of notices of violation regarding environmental permits?
.

5. Are all your products, packaging or components or their manufacture free of ozone depleting substances, including CFC's, halon, carbon tetrachloride, 1,1,1-trichloroethane and other substances listed under the Montreal Protocol?
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Product Material Composition

6. Is the product free of the following persistent bioaccumulative toxic pollutants (PBT's) and other chemicals? (This is a fairly long list of chemicals—please keep on trucking.)
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Metals: CAS Ref. #

Antimony 7440-36-0

Arsenic 7440-38-2

Beryllium 7440-41-7

Cadmium 7440-43-9

Chromium 7440-47-3

Copper 7440-50-8

Lead 7439-92-1

Mercury 7439-97-6

Nickel 7440-02-0

Selenium 7782-49-2

Silver 7440-22-4

Zinc 7440-66-6

Chlorinated Solvents:

1,1-Dichloroethane 75-34-3

1,1,1-Trichloroethane 71-55-6

Chloroform 67-66-3

Hexachloroethane

Chlorobenzenes:

1,2-Dichlorobenzene 95-50-1

1,3-Dichlorobenzene 541-73-1

1,4-Dichlorobenzene 106-46-7

1,2,4-Trichlorobenzene 120-82-1

1,2,4,5-Tetrachorobenzene 95-94-3

Pentachlorobenzene 608-93-5

Hexachlorobenzene 118-74-1

Other Halogenated Organics:

4-Bromophenyl phenyl ether 101-55-3

Ethylene Dibromide 106-93-4

Hexachlorobutadiene 87-68-3

Methyl Chloride 74-87-3

Methylene Chloride 75-09-2

Nonachlor

Octachlorostyrene 29082-74-4

Polychlorinated Biphenyls (PCBs)

Tetrachloroethane 127-18-4

Trichloroethylene 79-01-6

Pesticides:

2,4,5-Trichlorophenol 95-95-4

alpha-Endosulfan 959-98-8

Aldrin 309-00-2

beta-Endosulfan 33213-65-9

Chlordane 57-74-9

DDD 72-55-9

DDE 72-55-9

DDT 50-29-3

Dieldrin 60-57-1

Heptachlor 76-44-8

Heptachlor epoxide 1024-57-3

Lindane 58-89-9

Methoxychlor 72-43-5

Mirex 2385-85-5

Oxychlordane

Pentachloronitrobenzene 82-68-8

Pentachlorophenol 87-86-5

Toxaphene 8001-35-2

Phthalate esters:

Bis-(2-ethylhexyl) phthalate (DEHP) 117-81-7

Butylbenzylphthalate 85-68-7

Dibutyl phthalate 84-74-2

Diethyl phthalate 84-66-2

Dimethyl phthalate 131-11-3

Polycyclic aromatic hydrocarbons:

2-Methylnaphthalene 91-57-6

Acenaphthene 83-32-9

Acenapthylene 208-96-8

Anthracene 120-12-7

Benzo (a) anthracene 56-55-3

Benzo (k) fluoranthene 207-08-9

Benzo (g.h.l) perylene 191-24-2

Benzo (a) pyrene 50-32-8

Chrysene 218-01-9

Fluoranthene 206-44-0

Fluorene 86-73-7

Indeno (1,2,3) pyrene 193-39-5

Naphthalene 91-20-3

PAH group (as defined in TRI)

Phenanthrene 85-01-8

Pyrene 129-00-0

Other Chemicals:

2,4-Dinitrotulene 121-14-4

2,4,6-tris-(1,1-Dimethylethyl)phenol 732-26-3

Benzene 71-43-2

Cyanide 57-12-5

Dioxins (PCDD)

Ethylbenzene 100-41-4

Furans (PCDF)

Isophorone 78-59-1

Nitrobenzene 98-95-3

Phenol 108-95-2

Terphenyl 92-06-8

Toluene 108-88-3

Note: This table is a composite of chemicals from the automobile industry and Michigan Department of Natural Resources agreement on pollution prevention action plan for the Great Lakes and the Topical Reports Northwest Guide to PBTs. (www.pprc.org/pprc/pubs/topics/pbt.html#merc) Additional chemicals may be added in the future as they are determined to adversely impact human health or the environment

7. Is an MSDS sheet required for this product?
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8. Is this product free of mercury (Hg) (liquid reagents less than 10 ppb Hg)?
.

9. Is this product free of halogenated plastics such as polyvinyl chloride (PVC)?
.

10. Is this product free of required special permits or personal protective equipment for handling, storage and/or disposal as required by government regulations?
.

Manufacturing

11. Does your facility have an active program to reduce hazardous wastes?
.

12. Are your manufacturing processes free of materials that are required to be reported under the USEPA's toxic release inventory (TRI)?
.

13. Have manufacturing processes been evaluated for energy consumption and efforts made to practice energy conservation?
.

14. Does your facility use post-consumer recycled material in the manufacturing process?
.

15. Have manufacturing processes been evaluated for water consumption and efforts made to practice water conservation?
.

Packaging & Distribution

16. Is this product packaged in at least 50% post consumer recycled materials?

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17. Is this product packaged in materials that are free of chlorine bleached materials
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18. Is this product packaged in materials free of inks containing heavy metals (lead, mercury, cadmium, hexavalent chromium, etc.)?
.

19. Is this product packaged in materials free of halogenated plastics such as polyvinyl chloride (PVC)?
.

20. Are company arrangements or infrastructure in place to take back consumer product packaging from the user of this product for reuse and/or recycling?
.

Use and Service

21. Is this product free of chemicals and components, in its use or routine maintenance that require special handling or disposal procedures? (Example: mercury-containing reagents)
.

22. Does the use of this product produce only non-hazardous, non-biohazardous, or non-radioactive waste(s) when used?
.

23. Is this product free of chemical changes in its normal use that could be of concern (such as leaching of chemicals from the material)?
.

24. If electronic is this product designed to conserve energy use such as by incorporation of a "sleep mode"?
.

25. Is this product designed for easy replacement of those parts subject to wear so the entire unit does not require replacement?
.

End-of-Life

26. Is this product designed for easy separation to enhance reuse or remanufacture of components or recycling of materials?
.

27. Are product parts labeled to enhance separation and recycling?
.

28. Is this product free of materials that could be of concern if the product is landfilled, such as chemicals that could leach out of the product?
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29. Is the disposal of this product by incineration unlikely to create halogenated compounds such as dioxin?
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30. Are procedures in place or functioning to recover this product after primary use for reuse or recycling?
.

Supplier Environmental Summary

Add up the 1s. Highest score is 30. The lower the score the better.
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Please Print

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Name:

.

Title:

.

Date:

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E-mail Address:

.

Please return the questionnaire to the requesting organization.

Date:	.
Company Name:	.
Address:	.
City:	.
State/Province:	.
Zip Code:	.
Country:	.
Name of Person Responding:	.
Position/Title:	.
Phone Number:	.
Fax Number:	.
E-mail Address:	.

General Environmental Management Questions	Yes = 0 No = 1 Don't Know = 1
1. Does your company have an Environmental Management System in place such as ISO 14000 or EMAS?		.
2. Does your company regularly publish an environmental report that is available to the public?		.
3. Does your company regularly conduct internal environmental audits?		.
4. Is your company free of notices of violation regarding environmental permits?		.
5. Are all your products, packaging or components or their manufacture free of ozone depleting substances, including CFC's, halon, carbon tetrachloride, 1,1,1-trichloroethane and other substances listed under the Montreal Protocol?		.
Product Material Composition
6. Is the product free of the following persistent bioaccumulative toxic pollutants (PBT's) and other chemicals? (This is a fairly long list of chemicals—please keep on trucking.)		.
Metals:	CAS Ref. #
Antimony	7440-36-0
Arsenic	7440-38-2
Beryllium	7440-41-7
Cadmium	7440-43-9
Chromium	7440-47-3
Copper	7440-50-8
Lead	7439-92-1
Mercury	7439-97-6
Nickel	7440-02-0
Selenium	7782-49-2
Silver	7440-22-4
Zinc	7440-66-6
Chlorinated Solvents:
1,1-Dichloroethane	75-34-3
1,1,1-Trichloroethane	71-55-6
Chloroform	67-66-3
Hexachloroethane
Chlorobenzenes:
1,2-Dichlorobenzene	95-50-1
1,3-Dichlorobenzene	541-73-1
1,4-Dichlorobenzene	106-46-7
1,2,4-Trichlorobenzene	120-82-1
1,2,4,5-Tetrachorobenzene	95-94-3
Pentachlorobenzene	608-93-5
Hexachlorobenzene	118-74-1
Other Halogenated Organics:
4-Bromophenyl phenyl ether	101-55-3
Ethylene Dibromide	106-93-4
Hexachlorobutadiene	87-68-3
Methyl Chloride	74-87-3
Methylene Chloride	75-09-2
Nonachlor
Octachlorostyrene	29082-74-4
Polychlorinated Biphenyls (PCBs)
Tetrachloroethane	127-18-4
Trichloroethylene	79-01-6
Pesticides:
2,4,5-Trichlorophenol	95-95-4
alpha-Endosulfan	959-98-8
Aldrin	309-00-2
beta-Endosulfan	33213-65-9
Chlordane	57-74-9
DDD	72-55-9
DDE	72-55-9
DDT	50-29-3
Dieldrin	60-57-1
Heptachlor	76-44-8
Heptachlor epoxide	1024-57-3
Lindane	58-89-9
Methoxychlor	72-43-5
Mirex	2385-85-5
Oxychlordane
Pentachloronitrobenzene	82-68-8
Pentachlorophenol	87-86-5
Toxaphene	8001-35-2
Phthalate esters:
Bis-(2-ethylhexyl) phthalate (DEHP)	117-81-7
Butylbenzylphthalate	85-68-7
Dibutyl phthalate	84-74-2
Diethyl phthalate	84-66-2
Dimethyl phthalate	131-11-3
Polycyclic aromatic hydrocarbons:
2-Methylnaphthalene	91-57-6
Acenaphthene	83-32-9
Acenapthylene	208-96-8
Anthracene	120-12-7
Benzo (a) anthracene	56-55-3
Benzo (k) fluoranthene	207-08-9
Benzo (g.h.l) perylene	191-24-2
Benzo (a) pyrene	50-32-8
Chrysene	218-01-9
Fluoranthene	206-44-0
Fluorene	86-73-7
Indeno (1,2,3) pyrene	193-39-5
Naphthalene	91-20-3
PAH group (as defined in TRI)
Phenanthrene	85-01-8
Pyrene	129-00-0
Other Chemicals:
2,4-Dinitrotulene	121-14-4
2,4,6-tris-(1,1-Dimethylethyl)phenol	732-26-3
Benzene	71-43-2
Cyanide	57-12-5
Dioxins (PCDD)
Ethylbenzene	100-41-4
Furans (PCDF)
Isophorone	78-59-1
Nitrobenzene	98-95-3
Phenol	108-95-2
Terphenyl	92-06-8
Toluene	108-88-3
Note: This table is a composite of chemicals from the automobile industry and Michigan Department of Natural Resources agreement on pollution prevention action plan for the Great Lakes and the Topical Reports Northwest Guide to PBTs. (www.pprc.org/pprc/pubs/topics/pbt.html#merc) Additional chemicals may be added in the future as they are determined to adversely impact human health or the environment
7. Is an MSDS sheet required for this product?		.
8. Is this product free of mercury (Hg) (liquid reagents less than 10 ppb Hg)?		.
9. Is this product free of halogenated plastics such as polyvinyl chloride (PVC)?		.
10. Is this product free of required special permits or personal protective equipment for handling, storage and/or disposal as required by government regulations?		.
Manufacturing
11. Does your facility have an active program to reduce hazardous wastes?		.
12. Are your manufacturing processes free of materials that are required to be reported under the USEPA's toxic release inventory (TRI)?		.
13. Have manufacturing processes been evaluated for energy consumption and efforts made to practice energy conservation?		.
14. Does your facility use post-consumer recycled material in the manufacturing process?		.
15. Have manufacturing processes been evaluated for water consumption and efforts made to practice water conservation?		.
Packaging & Distribution
16. Is this product packaged in at least 50% post consumer recycled materials?		.
17. Is this product packaged in materials that are free of chlorine bleached materials		.
18. Is this product packaged in materials free of inks containing heavy metals (lead, mercury, cadmium, hexavalent chromium, etc.)?		.
19. Is this product packaged in materials free of halogenated plastics such as polyvinyl chloride (PVC)?		.
20. Are company arrangements or infrastructure in place to take back consumer product packaging from the user of this product for reuse and/or recycling?		.
Use and Service
21. Is this product free of chemicals and components, in its use or routine maintenance that require special handling or disposal procedures? (Example: mercury-containing reagents)		.
22. Does the use of this product produce only non-hazardous, non-biohazardous, or non-radioactive waste(s) when used?		.
23. Is this product free of chemical changes in its normal use that could be of concern (such as leaching of chemicals from the material)?		.
24. If electronic is this product designed to conserve energy use such as by incorporation of a "sleep mode"?		.
25. Is this product designed for easy replacement of those parts subject to wear so the entire unit does not require replacement?		.
End-of-Life
26. Is this product designed for easy separation to enhance reuse or remanufacture of components or recycling of materials?		.
27. Are product parts labeled to enhance separation and recycling?		.
28. Is this product free of materials that could be of concern if the product is landfilled, such as chemicals that could leach out of the product?		.
29. Is the disposal of this product by incineration unlikely to create halogenated compounds such as dioxin?		.
30. Are procedures in place or functioning to recover this product after primary use for reuse or recycling?		.
Supplier Environmental Summary
Add up the 1s. Highest score is 30. The lower the score the better.		.

Please Print	.
Name:	.
Title:	.
Date:	.
E-mail Address:	.