Title Page

  • Facility Name

  • Address
  • Assessed by

  • Conducted on

Legionella Risk Assessment Form

Facility Characteristics

  • Indicate the type of facility (select all that apply):

  • 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?

  • 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

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