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Water Systems Survey and Legionella Risk Assessment

Client

Site

GENERAL SITE & CLIENT DETAILS

Please enter client and site information

Site Photograph

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Client

Site

OVERALL RISK RATING

Low (carries a low risk and should be resolved if it is practical to do so)
Medium (carries a medium risk and must be managed)
High (carries a high risk and must be attended to as a matter of urgency)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Risk Rating

Client Contact Name

Client Telephone Number

Client Mobile Number

Client E-mail

Report Reference

Survey Date From

Survey Date to

Clean Water Systems Surveyor

Clean Water Systems Risk Assessor

(Qualifications enclosed)

Clean Water Systems Risk Assessor

Signature

Clean Water Systems Authorisation

Signature

Report Date

Recommended Review Date

Clean Water Systems Telephone Number

Clean Water Systems Email Address

RISK ASSESSOR'S INFORMATION

Please enter assessment & survey details

Risk Assessor's Name

Risk Assessor's Qualifications

Survey Date

Survey Date to

AMENDMENTS

There is no required time period necessary with respect to the review of this document.
However L8 states this should be a working document and should be part of all reviews connected with the legionella control programme.

The document must be reviewed under the following circumstances.
(a) changes to the water system or its use
(b) changes to the use of the building in which the water system is installed
(c) the availability of new information about risks or control measures
(d) the results of checks indicating that control measures are no longer effective
(e) changes to key personnel
(d) a case of legionnaires' disease/legionellosis associated with the system

Review Date

Building / System(s)

Changes required to Risk Assessment

Description of Change

Authorised by

Date

Review Date

Building / System(s)

Changes required to Risk Assessment

Description of Change

Authorised by

Date

Review Date

Building / System(s)

Changes required to Risk Assessment

Description of Change

Authorised by

Date

Review Date

Building / System(s)

Changes required to Risk Assessment

Description of Change

Authorised by

Date

Review Date

Building / System(s)

Changes required to Risk Assessment

Description of Change

Authorised by

Date

EXECUTIVE SUMMARY

HIGH RISK REMEIDIAL ACTIONS

These issues have been identified as high risk and the below remedial actions and / or controls must be attended to as a matter of urgency

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

MEDIUM RISK REMEDIAL ACTIONS

These issues have been identified as medium risk and the below remedial actions and / or controls must be managed

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

LOW RISK REMEDIAL ACTIONS

These issues have been identified as low risk and the below remedial actions and / or controls should be resolved if it is practical to do so

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

Location / System I.D

Remedial Action Summary

Completed by

Date of Completion

SCOPE OF SURVEY

Systems Included in the Survey

Systems Excluded in the Survey

System

Reason Excluded

Action Required

GNERAL SITE AND MANAGEMENT SYSTEM - SURVEY

Nominated Personnel

Statutory Duty Holder

Name (State if non-nominated or not required)

Address

Town/City

County

Post Code

Country

Phone

In their evidence of formal training?

Comments

Managerially Responsible Duty Holder

Name (State if non-nominated or not required)

Address

Town/City

County

Post Code

Country

Phone

In their evidence of formal training?

Comments

Deputy Managerially Responsible Duty Holder

Name (State if non-nominated or not required)

Address

Town/City

County

Post Code

Country

Phone

In their evidence of formal training?

Comments

Other Operational Staff who carry out Legionella Control

Name (State if non-nominated or not required)

Address

Town/City

County

Post Code

Country

Phone

In their evidence of formal training?

Comments

Water Treatment Contractor

Name (State if non-nominated or not required)

Address

Town/City

County

Post Code

Country

Phone

In their evidence of formal training?

Comments

Other Service Providers (including Maintenance Contractors)

Name (State if non-nominated or not required)

Address

Town/City

County

Post Code

Country

Phone

In their evidence of formal training?

Comments

Water Hygiene Monitoring of Domestic Water Systems and Scheme of Control

Control Scheme

Has a risk assessment been carried out previously?

Was the previous risk assessment made available for inspection?

Have all remedial actions from the previous risk assessment been completed and signed off?

Are there current and suitable schematic drawings in place?

Is there a current and suitable written scheme for controlling the risk from exposure to Legionella bacteria?

Does the scheme contain details of the precautions to be taken to control the risk of exposure to Legionella bacteria?

Does the scheme contain details of the checks to be carried out, their frequency and by whom, to ensure that the scheme is effective?

Water Hygiene Monitoring

Is there any suitable water hygiene monitoring taking place?

Is there a site specific Water Services Logbook on site?

Is the Logbook available for inspection?