Title Page
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Conducted on
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Prepared by
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Prepared for
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Property address
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Photo of property
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Make of Mixing Valve
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Model
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Valve Size
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Valve Location/Building
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Valve Identification Number
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Photo of Valve
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Total number of outlets served by this valve
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Details of other outlets
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Fail Safe Test
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Valve considered satisfactory for further use?
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Temperature as in HOSPLAN (referred to as the Code of Practice) page 54; section 7:
For Adults - 40.5 to 43.5°C
For Children - 38 to 40.5°C
For Neonatals (babies) - 35 to 38°C -
D and S Plumbing group
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Name of accredited tester
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Accreditation Number
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Temperature checked and Fail/Safe witnessed by
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Employed by
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Position held
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Testers Signature
