Cross-Connection Control Survey Form
Please complete this survey to help us assess and improve cross-connection control practices. Your feedback will inform our compliance and safety efforts.
Facility Type
*
Please Select
Commercial
Industrial
Residential
Institutional
Other
Are you aware of cross-connection risks in your facility?
*
Yes
No
Not sure
Which backflow prevention devices are installed at your facility?
*
Air gap
Double check valve
Reduced pressure zone device
None
Other
How often are cross-connection control devices inspected?
*
Annually
Every 2-3 years
Never
Not sure
Who is responsible for cross-connection control at your facility?
*
Please Select
Facility manager
Maintenance staff
External contractor
Not assigned
Other
Rate your facility’s compliance with cross-connection control regulations.
*
1
2
3
4
5
How confident are you in the effectiveness of your current cross-connection control measures?
*
Very confident
Somewhat confident
Not confident
Has your facility experienced any cross-connection incidents in the past 3 years?
*
Yes
No
Not sure
Please indicate your level of agreement with the following statements regarding cross-connection control at your facility.
*
Rows
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
We have a documented cross-connection control program.
1
2
3
4
5
Staff receive regular training on cross-connection control.
6
7
8
9
10
Maintenance records are kept up to date.
11
12
13
14
15
Backflow prevention devices are regularly tested.
16
17
18
19
20
Additional comments or suggestions
Submit Survey
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