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Legionella Checklist Template

This general legionella risk assessment form can be used to evaluate the premises. Record the cold and hot water temperatures and check that they are properly maintained. Assess whether the air conditioning and water systems are clean and disinfected. You may not need to take any further action at this time, but you can use the data you collect to periodically review the assessment if something changes in your system. Make full use of the evaluation possibilities by taking photos of risks in the workplace. Comment on the photos to highlight the underlying factors and report risks to safety managers and officials. Use the temperature field to enter the current temperature values. Generate reports in the field to improve the reporting process.
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Legionella Checklist Template

Audit

Legionella Risk Assessment

Is there any tenant, resident or regular visitor particularly suscetible to legionella due to age, health or lifestyle?

Did the person carrying out the assessment have access to competent help and advice when carrying out the assessment?

Take a photo of the cold water system

Provide a short description

Take a photo of the hot water system

Provide a short description

Water Outlet Temperature

Is the cold water temperature at water outlets below 20° Celsius?

Temperature in Celsius:

Is the hot water temperature at water outlets above 50° Celsius?

Temperature in Celsius:

Cold Water System

Cold water storage tank location (photo)

Is a cold water storage tank present?

Is the cold water tank accessible?

Does the tank have a tight fitting lid?

Is the water in the tank clean and free from rust, debris, scale, and organic matter?

Is the temperature of the water in the tank below 20 ° celsius?

Temperature in Celsius:

Is the cold water tank insulated?

Hot Water System

Is the temperature setting on the boiler and/or hot water tank such that hot water is heated to and stored at a temperature of 60 ° celsius?

Are the hot water distribution pipes insulated?

If more than one calorifier is used, are they connected in parallel?

Is the water heater equipped as follows?

Does it have a drain valve?

Does it have a temperature gauge on the inlet and outlet?

Does it have an access panel?

Little Used Outlets

Are there any water outlets are used less than once per week e.g. guest bathrooms?

Is there any provision to flush them at least once a week?

Showers

hotograph the location of the shower.

Take photo of shower location

Dead Legs and Redundant Pipework

Pipeline sections that are superfluous or have low/no flow due to the system design (so-called "dead sections") can cause the water in the system to stagnate.

Are there any dead sections on the property?

Taking pictures.

Unoccupied Properties

Are objects on the property not used for a certain time?

Are there arrangements in place to flush them through on at least a weekly basis?

Confirmation

Full Name and Signature of Landlord

Full Name and Signature of Legionella Responsible Person

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