Legionella Site Audit Form

Legionella Site Audit Form
Complete this form to document your Legionella risk assessment and site inspection. Ensure all sections are filled for a thorough audit record.
Site Name and Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Site Contact Person (Full Name)
First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date and Time of Inspection
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Inspector's Name
First NameLast Name
Water Systems Present (select all that apply)
Other
Water System Assessment Table
Rows Condition Temperature (°C) Evidence of Stagnation
Hot Water System
Cold Water System
Cooling Towers
Spa Pools
Compliance Checklist (select all that are compliant)
Other
Overall Legionella Risk Rating

1
2
3
4
5
1 is Low, 5 is High
Recommendations and Actions Required
Upload Photos or Supporting Documents (if any)
Cancelof
Inspector's Signature
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