Legionella Risk Assessment Form
This legionella risk assessment form is based on the Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form used to gain a thorough understanding of a facility’s water systems and assist facility management with minimizing the risk of legionellosis.
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Cut inspection time by 50% Uncover more issues and solve them 4x faster Select from over 4000 expert-proofed templates Legionella Risk Assessment Form Facility Characteristics Indicate the type of facility (select all that apply): Select Senior living facility (e.g., retirement home without skilled nursing care) Other residential building (e.g., apartment, condominium) Hotel, motel, or resort Recreational facility (e.g., health club, water park) Office building Manufacturing facility Restaurant Other Does occupancy vary throughout the year? Yes No Seasons with lowest occupancy (check all that apply): Winter Spring Summer Fall Are any occupant rooms taken out of service during specific parts of the year, e.g., low season? Yes No Average length of stay for occupants: 1 night 2-3 nights 4-7 nights >7 nights Does the facility have emergency water systems (e.g., fire sprinklers, safety showers, eye wash stations)? Yes No Are these systems regularly tested (i.e., sprinkler head flow tests)? Yes No Does the facility have centralized humidification (e.g., on air-handling units) or any room humidifiers? Yes No Has this facility been associated with a previous legionellosis cluster or outbreak? Yes No Does the facility have a water safety plan or Legionella prevention program? Yes No Does the facility ever test for Legionella in water samples? Yes No Obtain copies of results. Water Supply Source What is the source of the water used by the facility? Select Senior living facility (e.g., retirement home without skilled nursing care) Other residential building (e.g., apartment, condominium) Hotel, motel, or resort Recreational facility (e.g., health club, water park) Office building Manufacturing facility Restaurant Other How is the municipal water disinfected? Chlorine Monochloramine Other Has treatment of municipal water changed in the past year? Yes No How is the well water disinfected? Chlorine Other Not disinfected Is the water filtered onsite? Yes No Have there been any pressure drops, boil water advisories, or water disruptions (e.g., water main break) to the facility in the past 6 months? Yes No Does the facility monitor incoming water parameters (e.g., residual disinfectant, temperature, pH)? Yes No Obtain copies of the logs Premise Plumbing System Are cisterns and/or water storage holding tanks used to store potable water before it’s heated? Yes No Is there a recirculation system (a system in which water flows continuously through the piping to ensure constant hot water toall endpoints) for the hot water? Yes No Are thermostatic mixing valves used? Yes No Are hot water temperatures ever measured by the facility at the points of use? Yes No Obtain copies of the temperature logs. Are the potable water disinfectant levels (e.g., chlorine) ever measured by the facility at the points of use? Yes No Obtain copies of the logs. Does the facility have a supplemental disinfection system for long term control of Legionella or other microorganisms? Yes No Obtain SOPs for routine use and maintenance as well as maintenance logs and records of disinfection levels. Completion Epidemiologist Name & Signature Environmental Health Specialist Name & Signature Public Health Offical Name & Signature
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.