Legionella risk assessment form checklist
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.
What does this form include?
This form contains 13 sections:
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
- Does occupancy vary throughout the year?
- Are any occupant rooms taken out of service during specific parts of the year, e.g., low season?
What is the source of the water used by the facility?
Water Supply Source
- 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?
- Does the facility monitor incoming water parameters (e.g., residual disinfectant, temperature, pH)?
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 toall endpoints) for the hot water?
- Are thermostatic mixing valves used?
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
Use this template