Question sheet to accompany application form Acupuncture Please answer these questions in BLOCK CAPITALS and return it with your completed application form to this office. Name: ......................................................................................................................... Home Address: ........................................................................................................... Telephone Number: .................................................................................................... Address of Business: .................................................................................................. Telephone Number: .................................................................................................... Email Address: ........................................................................................................... Working hours/days: ................................................................................................... 1. Describe any use of the acupuncture room other than for giving treatment. ........................................................................................................................... 2. Where were you trained to carry out this treatment and do you hold a certificate? ........................................................................................................................... 3. Is general waste material stored in: (a) A washable and leakproof covered receptacle or (b) A leakproof lining bag inside a covered receptacle 4. How often are these bins emptied? ........................................................................................................................... 5. Describe your method for ensuring that only sterile needles are used. .......................................................................................................................... .......................................................................................................................... 6. State how and where damaged/used needles are disposed of and the type of container they are stored in. .......................................................................................................................... Page 1 of 3 7. Do you re-cap or treat your used needles before disposal/sterilisation? .......................................................................................................................... 8. Does your table/couch/seat have an impervious cover? .......................................................................................................................... 9. How often are these items wiped with disinfectant, and what product(s) do you use? .......................................................................................................................... 10. Do you use a disposable paper sheet on your table/couch? .......................................................................................................................... 11. How often is this changed? .......................................................................................................................... 12. Do you prominently display a “No Smoking” notice in the treatment area? .......................................................................................................................... 13. Are all gowns/wraps/towels etc clean and not used on any previous patient? .......................................................................................................................... 14. Are other items of equipment (tweezers, trays, kidney dishes etc) disposable or sterilisable? .......................................................................................................................... 15. Explain how you would dispose of contaminated waste? (paper sheets) .......................................................................................................................... 16. Describe the type of flooring in the treatment room? .......................................................................................................................... 17. Are there sufficient gas/electrical points for your requirements? (Adaptors and trailing leads are not recommended). .......................................................................................................................... 18. Is there sufficient storage to ensure that items such as towels/gowns/cleaning materials/sterile needles, etc can be free from the risk of contamination? .......................................................................................................................... Page 2 of 3 19. Do you have readily available a first aid kit including gloves? .......................................................................................................................... 20. Are washing facilities for your use in the treatment room or very nearby? (Shared household facilities are not recommended). .......................................................................................................................... 21. What type of hand drying provision do you use? .......................................................................................................................... 22. Is there a provision of: hot and cold water; soap (preferably liquid); and a nail brush? .......................................................................................................................... 23. Is there a toilet? ............................................................................................... 24. How long do you keep records of clients details and the treatment given? .......................................................................................................................... 25. Does your premises contain a sunbed/sauna/spa pool (jacuzzi)? .......................................................................................................................... Thank you for your co-operation. Inspector’s notes only please. 1. Health and Safety Regulations. 2. Internal walls, doors etc. 3. Furniture and fittings. 4. Facilities for sterilising and cleansing. 5. Operator hygiene. 6. Comments. Pass/Fail to register Improvements required: Revisit date: Page 3 of 3