• Client / Site

  • Location
  • Personnel

  • Conducted on

0.0 Premises details

  • Premises name

  • Premises address
  • Owner/s details

  • Owners contact details

1.0: Notification

  • 1.1: Have you notified Council in writing of any cooling towers or evaporative condensers (notifiable devices) on the premises?

  • Requirement under Public Health Regulations 2012

  • 1.2: Has there been any changes to the cooling tower or evaporative condensers since the last notification?

  • You must notify Council of any changes to the notification information within one month of the change, and if If the device ceases to be a notifiable device you must notify the council in writing as soon as possible. Note: There is no fee for this application

2.0: Risk Assessment

  • 2.1: Has a risk assessment been carried out for the cooling tower, evaporative condensers, warm water systems or the like and for the control of Legionellasis?

  • If so when was the Risk Assessment last Reviewed ?

  • 2.2: Is the risk assessment suitable and sufficient?

  • 2.3: Were the plant operators involved with this risk assessment?

  • 2.4: Are duties clearly defined for employees and contractors?

  • 2.5: Has a scheme of control been created for controlling the risk?

3.0: Roles and Responsibilities

  • 3.1: Who has been assigned responsibility for the Cooling Tower/s, Evaporative Condenser/s, or Warm Water System/s or the like

  • 3.2: Has this person had any training in the control of legionella bacteria in water systems?

  • 3.3: Are the duties clearly defined for employees and contractors when working with the Cooling Tower system?

4.0: Routine Checks and Maintenance

  • 4.1: When was the last full inspection carried out?

  • If no details available record additional information here.

  • 4.2: Was the person who carried out this inspection competent (i.e. any training certificates etc)?

  • 4.3: Are dosing pumps where fitted calibrated regularly?

  • 4.4: Are the drift eliminators inspected and maintained in good order?

  • 4.5: Was there any visible signs of a build up of slime, algae, scale or corrosion?

  • 4.6: Was any broken or damaged equipment reported?

5.0: Water Treatment

  • 5.1: Do you use up-­to­-date, appropriate disinfection techniques?

  • 5.2: How often do you check the water quality?

  • 5.3: Do you incubate dipslides properly?

  • 5.4: Do you record and complete your remedial actions in a timely manner?

6.0: Cleaning and Disinfection

  • 6.1: Have you carried out a clean and disinfection in the last 6 months?

  • 6.2: When was the packing removed for a deep clean?

  • If no details available record additional information here.

  • 6.3: When was the system fully drained down (e.g. at last long shutdown)?

  • If no details available record additional information here.

  • 6.4: Are the cleaning procedures site specific and robust enough to cover all risks (i.e. everyone protected during cleaning)?

7.0: Emergency Response

  • 7.1: Has an emergency plan been prepared? (Legionellosis (ie all diseases caused by legionella) is notifiable under the Public Health Regulation 2012

  • As part of the outbreak investigation and control, the following requests and recommendations may be made by the enforcing authority.
    (a) To shut down any processes which are capable of generating and disseminating airborne water droplets and keep them shut down until sampling procedures and any remedial cleaning or other work has been done. Final clearance to restart the system may be required.
    (b) To take water samples from the system before any emergency disinfection being undertaken. This will help the investigation of the cause of the illness. The investigating officers from the local authority/ies may take samples or require them to be taken.
    (c) To provide staff health records to discern whether there are any further undiagnosed cases of illness, and to help prepare case histories of the people affected.
    (d) To co-operate fully in an investigation of any plant that may be suspected of being involved in the cause of the outbreak. This may involve, for example:
    (i) tracing of all pipework runs;
    (ii) detailed scrutiny of all operational records;
    (iii) statements from plant operatives and managers;
    (iv) statements from water treatment contractors or consultants.

  • 7.2: Does the plan contain details for Emergency cleaning and disinfection?

  • Emergency cleaning and disinfection procedure for cooling towers If a cooling water system has been implicated in an outbreak of Legionnaires’ disease emergency cleaning of that system has to take place as soon as possible. The following actions should be taken, where appropriate: (a) switch off the fan immediately; (b) take samples for laboratory investigation before any further action; (c) switch off the circulation pump as soon as is practicable and the system decommissioned; (d) consult the enforcing authority before proceeding further; (e) keep all personnel clear of the tower area; (f) when cleared by the enforcing authority, add sodium hypochlorite to the system water to obtain a measured concentration of 50 mg/l of free chlorine; (g) circulate the system water with the fans off for a period of at least six hours; (h) maintain the free chlorine level at an absolute minimum of 20 mg/l at all times; (i) use a suitable biodispersant; (j) after six hours, de-chlorinate and drain the system; (k) undertake manual cleaning of the tower, sump, and distribution system with cleaning staff wearing fully pressurised respirators; (l) refill with fresh water, add sodium hypochlorite; (m) recirculate without using the fan, at 20 mg/l of free available chlorine for six hours; (n) de-chlorinate and drain the system; (o) refill, recirculate and take samples for testing: (p) re-commission system when test results detect no legionella and/or permission is granted by the enforcing authority. If a water system other than a cooling system is implicated in an outbreak of Legionnaires’ disease, emergency treatment of that system should be carried out as soon as possible.

  • 7.3: Does the plan have a media draft statement prepared?


  • Site Representative

  • Auditor

  • Date completed

  • Revision 1: 20 March 2014

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.