Domestic Water Systems Legionella Risk Assessment

• Report Number

• Client

• Site

  Select

• Site Address

• Conducted on

  Date

• Prepared by

• Date

  Date

• SAFE WATER IO LIMITED Document Control

• SAFE WATER IO LIMITED has prepared this report for the sole use of the client, showing reasonable skill and care, for the intended purposes as stated in the agreement under which this work was completed. The report may not be relied upon by any other party without the express agreement of the client and SAFE WATER IO LIMITED. No other warranty, expressed or implied, is made as to the professional advice included in this report.

• Where any data supplied by the client or from other sources have been used, it has been assumed that the information is correct. No responsibility can be accepted by SAFE WATER IO LIMITED for inaccuracies in the data supplied by any other party. The conclusions and recommendations in this report are based on the assumption that all relevant information has been supplied by those bodies from whom it was requested.

• No part of this report may be copied or duplicated without the express permission of SAFE WATER IO LIMITED and the party for whom it was prepared.

• Where field investigations have been carried out, these have been restricted to a level of detail required to achieve the stated objectives of the work. This work has been undertaken in accordance with the quality management system of SAFE WATER IO LIMITED.

Description of System

• Systems Present

• Domestic Hot Water

  Yes

  No

  N/A

• Domestic Cold Water

  Yes

  No

  N/A

• Potable Water

  Yes

  No

  N/A

• Showers / Spray Outlets

  Yes

  No

  N/A

• Solar Hot Water Systems

  Yes

  No

  N/A

• Vending Machines

  Yes

  No

  N/A

• Rain Water Recycling System

  Yes

  No

  N/A

• Fire Suppression System

  Yes

  No

  N/A

• Closed Systems Heating

  Yes

  No

  N/A

• Closed Systems Chilled

  Yes

  No

  N/A

• Systems Surveyed

• Domestic Hot Water

  Yes

  No

  N/A

• Domestic Cold Water

  Yes

  No

  N/A

• Potable Water

  Yes

  No

  N/A

• Showers / Spray Outlets

  Yes

  No

  N/A

• Solar hot Water Systems

  Yes

  No

  N/A

• Vending Machines

  Yes

  No

  N/A

• Rain Water Recycling System

  Yes

  No

  N/A

• Fire Suppression System

  Yes

  No

  N/A

• Closed Systems Heating

  Yes

  No

  N/A

• Closed Systems Chilled

  Yes

  No

  N/A

• Exclusions SAFE WATER IO LIMITED will endeavour to access all areas as per the Scope of Works; however, sometimes it is not safe, practical or reasonable to do so during a risk assessment survey. In the eventuality of this, in section 7.1 "Risk Rating v Actions", we have listed potential areas where we believe there could be outlets and plant which have not been accessed.
  If there are any other areas you feel were not surveyed and should be included in the risk assessment, please notify the Project Manager identified in the SAFE WATER IO LIMITED Document Control Section.

• Duty Holder: This person is the employer where the risk from their undertaking is to their employees or others or a self-employed person where there is a risk from their undertaking

• Name:

• Title:

• Company:

• Address:

• Tel Nos:

• Nominated Responsible Person: This person has been appointed by the duty holder to be responsible for the day to day control and prevention of Legionella bacteria. They should ensure that all control & prevention works are completed adequately. This person has the responsibility to maintain & keep all the records. This person has the responsibility to ensure that personnel & contractors involved in performing the regime are competent to do so.

• Name:

• Title:

• Company:

• Address:

• Tel Nos:

• Deputy Nominated Responsible Person: This person has been delegated by the Duty of Care Holder & Responsible Person. This person has the responsibility to perform the same duties as the Responsible Person in instances of absenteeism or changes in personnel. This person should have a deputy at times of absence.

• Name:

• Title:

• Company:

• Address:

• Tel Nos:

• Health And Safety Manager Or Advisor: This person has been delegated by the Duty Holder & Responsible Person. This person has the responsibility to act on behalf of the named client as its Health & Safety Advisor.

• Name:

• Title:

• Company:

• Tel Nos: --

• Address:

• Tel Nos: --

• The Person(S)) Responsible For The Completion Of Tasks Associated With Legionella Control This person has been delegated by the Responsible Person to carry out monitoring procedures in accordance with HSG274 for the control and prevention of Legionella bacteria. All procedures are overseen by the Responsible Person and Duty Holder.

• Name:

• Title:

• Company:

• Address:

• Tel Nos:

• Water

• Water Hygiene Contractor: State the name of the Duty Holder on behalf of the Company who have been nominated in performing specialist contracted services as in accordance with the requirements of HSG274 to the water systems upon this site.

• Name:

• Title:

• Company:

• Address:

• Tel Nos:

• General Description of the Property / Water Services

General Information

• Is there a previous risk assessment?

  Yes

  No

  N/A

• Is the risk assessment current?

  Yes

  No

  N/A

• Is there a water hygiene logbook?

  Yes

  No

  N/A

• Was the logbook made available for inspection?

  Yes

  No

  N/A

• Is the logbook up to date?

  Yes

  No

  N/A

• Does the logbook detail a complete and up to date management and responsibility structure?

  Yes

  No

  N/A

• Does the logbook detail an action plan for non-conformance Legionella results?

  Yes

  No

  N/A

• Does the logbook detail the required tasks and frequencies?

  Yes

  No

  N/A

• Is there a remedial log sheet?

  Yes

  No

  N/A

• Is there a written scheme in place?

  Yes

  No

  N/A

• Is the written scheme being adhered to?

  Yes

  No

  N/A

• Are potable water outlets clearly marked?

  Yes

  No

  N/A

• Are there training records for individuals involved in the control and prevention of Legionella bacteria?

  Yes

  No

  N/A

• Notes:

Susceptibility of Individuals

• State the estimated current population density within the premises?

• State the estimated anticipated population density within the premises?

• Are any of the occupiers classified as susceptible i.e. on immunosuppressants?

  Yes

  No

  N/A

• Occupants of age group 45 - 70?

  Yes

  No

  N/A

• Does the building have a water system which may affect the public outside of the premises?

  Yes

  No

  N/A

• Do the general public come into contact with any of the water systems within any of the buildings?

  Yes

  No

  N/A

• Has a recorded case of legionnaire's disease been associated with this site?

  Yes

  No

  N/A

• Has a recorded case of legionnaire's disease been associated with any of the water systems?

  Yes

  No

  N/A

• Notes:

Cold Water Storage Cistern (Tank)

• Is there a record of annual cold water storage tank(s) inspection(s)?

  Yes

  No

  N/A

• Is there a record of annual cold water storage tank temperature monitoring?

  Yes

  No

  N/A

• Is there a record of annual cold water storage tank make up temperature monitoring?

  Yes

  No

  N/A

• Do the tank(s) comply with the Water Supply (Water Fittings) Regulations 1999?

  Yes

  No

  N/A

• Has any remedial works been completed on the tank(s)

  Yes

  No

  N/A

• Are temperatures recorded within HSG274 Part 2 Guidelines?

  Yes

  No

  N/A

• Are there any cleaning & disinfection records

  Yes

  No

  N/A

• Are any regular bacteriological monitoring sampling & analysis undertaken?

  Yes

  No

  N/A

• Are any regular Legionella sampling analysis undertaken?

  Yes

  No

  N/A

• Notes:

  Yes

  No

  N/A

Calorifiers / Hot Water Heaters

• Is there a record of annual opening & inspections of calorifiers?

  Yes

  No

  N/A

• Is there a record of annual drain sampling?

  Yes

  No

  N/A

• Are there any cleaning & disinfection records?

  Yes

  No

  N/A

• If the answer to the above is No - is the system pasteurised?

  Yes

  No

  N/A

• Is the flow temperature monitored monthly?

  Yes

  No

  N/A

• Is the return temperature monitored monthly?

  Yes

  No

  N/A

• Are temperatures recorded within HSG274 Part 2 guidelines?

  Yes

  No

  N/A

• Are any regular bacteriological monitoring tests undertaken?

  Yes

  No

  N/A

• Are any regular Legionella tests undertaken?

  Yes

  No

  N/A

• Notes:

Hot Water Heaters and Cylinders

• Is there a record of any annual inspections?

  Yes

  No

  N/A

• Are there any cleaning & disinfection records?

  Yes

  No

  N/A

• Is the nearest outlet temperature monitored monthly?

  Yes

  No

  N/A

• Are Temperatures recorded within HSG274 Part 2 guidelines?

  Yes

  No

  N/A

• Are any regular bacteriological monitoring sampling & analysis undertaken?

  Yes

  No

  N/A

• Are any regular Legionella sampling & analysis undertaken?

  Yes

  No

  N/A

• Notes:

undefined

• Yes

  No

  N/A