Template Information
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.
Category: general
Template Questions
- Indicate the type of facility (select all that apply):
- Total number of rooms that can be occupied overnight (e.g., patient rooms, hotel rooms):
- Facility Characteristics
- What is the source of the water used by the facility?
- Water Supply Source
- Premise Plumbing System
- What is the maximum hot water temperature at the point of delivery permitted by state / local regulations?
- Describe any maintenance (either routine or emergency) carried out on the potable water system in the past year.
- Additional Recommendations
- Epidemiologist Name & Signature
- Environmental Health Specialist Name & Signature
- Public Health Offical Name & Signature
- Name & Job Title