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Legionella Risk Assessment Form

Legionella Risk Assessment Form

Use this legionella risk assessment form to get an overview of the water system of a facility and minimize the risk of legionellosis.

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Legionella Risk Assessment Form

Use this legionella risk assessment form to get an overview of the water system of a facility and minimize the risk of legionellosis.

Use this template with Lumiform

The Lumiform application helps frontline teams uphold internal standards effortlessly.
  • Customize this template or build your own
  • Fill out templates via mobile app
  • Assign and track corrective actions
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

This legionella risk assessment form is based on the Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form used to gain a thorough understanding of a facility’s water systems and assist facility management with minimizing the risk of legionellosis.

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Preview of the template
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 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
Name & Job Title
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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.