Self-Declaration Form

European Union (Mercury) Regulations 2018

Date*

Date of completion of form

Name of Dentist / Dental Practice

Person completing the self-declaration*

First NameLast Name

Position held of person completing the self-declaration*

Office Phone Number*

Area CodePhone Number

Phone Number

PrefixNumber

Email*

example@example.com

Website

Registered Address of Dentist / Dental Practice *

Street Address

Street Address Line 2

CityCounty

Eircode

Does the practice have a dental amalgam separator(s) in service?*

If you do not have a dental amalgam separator, please insert reason /comment here:

Some specialist dentists do not use amalgam and do not treat patients with amalgam filling/remove amalgam fillings). Please comment.

If Yes, please tick indicate relevant date of installation of amalgam separator

Date

Is amalgam separator regulated to EU standard or equivalent?

A separator meeting the EU standard would be evidence of conformity to 95% level.

Is the retention level of amalgam separator(s) at least 95%?

(a)Amalgam separators put into service from 1 January 2018 provide a retention level of at least 95% of amalgam particles; and (b) From 1 January 2021, all amalgam separators in use provide the retention level specified in point (a).

If not, please provide comment:

Are records of retention levels maintained? Please attach documents below

Is the amalgam separator present on a suction system?

If separators have a shared suction unit which is not in the same room, this should be noted here.

Is the amalgam separator(s) maintained in accordance with the manufacturer’s instructions?

If yes, please attach records in relation to inspection frequency

File Upload

Dental practitioners shall ensure that their amalgam waste, including amalgam residues, particles and fillings, and teeth, or parts thereof, contaminated by dental amalgam, is handled and collected by an authorised waste management establishment or undertaking.

The reference in Article 10(6) to “authorised waste management establishment or undertaking” shall be construed as an operator that holds a Waste Collection Permit within the meaning of section 34 of the Waste Management Act 1996 (No. 10 of 1996) for the purposes of handling and collecting amalgam waste.

Has an Authorised Waste Collector been engaged to service the collection of amalgam waste, including amalgam residues, particles and fillings, and teeth, or parts thereof, contaminated by dental amalgam?*

YesNo

Name of Authorised Waste Collector*

NWCPO number of Authorised Waste Collector*

If yes to above, provide documentary evidence such as customer account number(s), receipts, statements or other proof of payment to demonstrate the existence of this engagement? *

Note: this information will be verified by DLRCC

Does the practice use UN Certified Waste Containers for:

Amalgam residues, particles & fillings?Amalgam Capsules?

Does the practice use a Tooth box / boxes for Storage of Extracted teeth?

Declaration:

I hereby certify that all the information provided is correct:

Signed

Date

NOTES:

Enforcement of Article 10(4) and 10(6) of REGULATION (EU) 2017/852 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 17 May 2017 on mercury, and repealing Regulation (EC) No 1102/2008 requires that:

Each local authority shall monitor compliance by operators of dental facilities situated within its functional area with the following:

1) From 1 January 2019, operators of dental facilities in which dental amalgam is used or dental amalgam fillings or teeth containing such fillings are removed, shall ensure that their facilities are equipped with amalgam separators for the retention and collection of amalgam particles, including those contained in used water.

Such operators shall ensure that:

Amalgam separators put into service from 1 January 2018 provide a retention level of at least 95 % of amalgam particles; and
From 1 January 2021, all amalgam separators in use provide the retention level specified in point A.

Amalgam separators shall be maintained in accordance with the manufacturer's instructions to ensure the highest practicable level of retention.

2) Dental practitioners shall ensure that their amalgam waste, including amalgam residues, particles and fillings, and teeth, or parts thereof, contaminated by dental amalgam, is handled and collected by an authorised waste management establishment or undertaking. Dental practitioners shall not release directly or indirectly such amalgam waste into the environment under any circumstances.

3) All data supplied will be processed in accordance with the Council's Data Protection Privacy Statement available here.

Self-Declaration Form

Contact Details