Title Page

  • Pool

  • Conducted on

  • Pool Operator/Pool Manager

  • Location


  • Type of pool

  • Describe other:

Safety questions

  • Does a 4-foot barrier surround the entire pool?

  • Does the barrier around the pool limit the open area to pool related activities only? (Unrelated ancillary activities within the pool area are: food stands; play areas; picnic tables; barbecues, etc.)

  • Are all gates self-latching?

  • Are all gates are self-closing?

  • Are all gates lockable at 4 and 1/2 feet?

  • Are locks available for all gates?

  • Are keys and locks kept where children cannot reach them?

  • Is the wading (kiddy) pool separated from the main pool by a four-foot barrier?

  • Are pH and chlorine tests kits used to test the water quality regularly?

  • Are pools free of entrapment and disembowelment hazards?

  • Is the pool deck non-slip and free of irregularities and fittings on walkway?

  • Are pool rules posted for community use pools?

  • Are depths marked at the side of the pool for each one-foot change?

  • Is diving from the side of the pool prohibited where pool depths are less than 9 feet deep?

  • Is diving from a diving board prohibited where pool depths are less than 11.5 feet and where the distance to the slope for the shallow end is less than 16 feet?

  • Is a certified lifeguard/designated responsible person on duty whenever children 16 years or younger are within the pool area (community use pools)?

  • Is the required rescue and emergency response equipment situated within the pool area?

  • Is there an emergency action plan in effect including plan implementation training?

  • Are all electrical outlets in the pool area covered and GFCI protected?

Sign off

  • Comments

  • Name and Signature

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