Title Page
-
Facility Name
-
Address
-
Assessed by
-
Conducted on
Legionella Risk Assessment Form
Facility Characteristics
-
Indicate the type of facility (select all that apply):
- 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
-
Specify
-
Total number of rooms that can be occupied overnight (e.g., patient rooms, hotel rooms):
-
Does occupancy vary throughout the year?
-
Seasons with lowest occupancy (check all that apply):
-
Are any occupant rooms taken out of service during specific parts of the year, e.g., low season?
-
Which rooms?
-
Average length of stay for occupants:
-
Does the facility have emergency water systems (e.g., fire sprinklers, safety showers, eye wash stations)?
-
Are these systems regularly tested (i.e., sprinkler head flow tests)?
-
How often?
-
Date of last test
-
Does the facility have centralized humidification (e.g., on air-handling units) or any room humidifiers?
-
Describe their location and operation:
-
Has this facility been associated with a previous legionellosis cluster or outbreak?
-
Please describe the number of cases, dates, source if found, and any interventions (immediate and long-term) to prevent recurrence:
-
Does the facility have a water safety plan or Legionella prevention program?
-
Describe the plan briefly here (does it include clinical disease surveillance and/or environmental Legionella surveillance?) and obtain a written copy of the program policy:
-
Does the facility ever test for Legionella in water samples?
-
Obtain copies of results.
Water Supply Source
-
What is the source of the water used by the facility?
- Municipal water
- Non-municipal water
- Other
-
Name of supplier
-
How is the municipal water disinfected?
-
Specify
-
Has treatment of municipal water changed in the past year?
-
Specify
-
How is the well water disinfected?
-
Specify
-
Is the water filtered onsite?
-
SSpecify the other source of water
-
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?
-
Describe what happened and which buildings or parts of buildings were affected:
-
Does the facility monitor incoming water parameters (e.g., residual disinfectant, temperature, pH)?
-
Obtain copies of the logs
-
What is the range of disinfectant residual, temperature, and pH entering the facility?
Premise Plumbing System
-
Are cisterns and/or water storage holding tanks used to store potable water before it’s heated?
-
Is there a recirculation system (a system in which water flows continuously through the piping to ensure constant hot water to<br>all endpoints) for the hot water?
-
Describe where it runs and delivery/return temperatures if they are measured:
-
Are thermostatic mixing valves used?
-
Describe where they are located (ideally, mixing valves are close to the point of use):
-
What is the maximum hot water temperature at the point of delivery permitted by state / local regulations?
-
Are hot water temperatures ever measured by the facility at the points of use?
-
Obtain copies of the temperature logs.
-
What is the lowest documented hot water temperature measured at any point within the facility?
-
Are the potable water disinfectant levels (e.g., chlorine) ever measured by the facility at the points of use?
-
Obtain copies of the logs.
-
How often are they measured?
-
List the range of disinfectant residuals.
-
Does the facility have a supplemental disinfection system for long term control of Legionella or other microorganisms?
-
Obtain SOPs for routine use and maintenance as well as maintenance logs and records of disinfection levels.
-
Describe any maintenance (either routine or emergency) carried out on the potable water system in the past year.
Completion
-
Additional Recommendations
-
Epidemiologist Name & Signature
-
Environmental Health Specialist Name & Signature
-
Public Health Offical Name & Signature
Person(s) interviewed during assessment
-
Name & Job Title