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Legionella Checklist Template

Legionella Checklist Template

Use this legionella checklist template to evaluate the condition on site.

Use this template
or download pdf
Legionella Checklist Template

Use this legionella checklist template to evaluate the condition on site.

Use this template
or download pdf

About the 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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Preview of the 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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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.
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