Environmental Health Systems Approach to Recreational Water Illness
Prevention

*- Information Collection Tool for Understanding How the Aquatic
Facility Works -*

Facility:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date(s):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
City, State, Zip:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact/Position:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Telephone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Email:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+-----------------------------------------------------------------------+
| Note to Environmental Health Specialist:                              |
|                                                                       |
| This data collection tool may be used where a thorough understanding  |
| of the integrated environmental health system of equipment,           |
| processes, people/policies, and economics is needed of an aquatic     |
| facility to better assess contributing factors during an outbreak     |
| investigation. It may also be used to assist the facility management  |
| to better control the factors that may impact the prevention          |
| practices. It should be completed in as much detail as possible. Not  |
| all the information specified may be available to environmental       |
| health specialists or applicable for every aquatic facility.          |
|                                                                       |
| Completion of the form may take several hours -- please keep in mind  |
| that this initial investment of time is quite important. In following |
| years, only changes to the facility need to be addressed after the    |
| initial data collection is done. Please do not leave sections blank.  |
| If a question doesn't apply, write N/A. If a question can't be        |
| answered please explain why. Where applicable, please specify the     |
| unit of measurement being used (e.g., meters vs. feet).               |
|                                                                       |
| Throughout this form the term "pool" will be generically used for     |
| individual water features such as spa, splash area, and water slide,  |
| as well as for a swimming pool. Use the chart below to link the       |
| collected data back to a specific aquatic feature. In the data        |
| collection, if there is more than one pool, specify whether answers   |
| apply to all pools, or just one. This form does not include space for |
| more than four pools. Use multiple forms if more pools are included   |
| (e.g., at a water park). If available, please attach a plan review    |
| diagram to this assessment. If the facility has a map, please         |
| include. If no map or plan review diagram is available, make a sketch |
| in the space provided on the last page, and/or attach labeled         |
| photographs.                                                          |
|                                                                       |
| It is recommended that if you are completing the form electronically, |
| you use a different font and/or italics for your answers. This will   |
| make the form much easier to read if additional information is added  |
| in the future to an existing form.                                    |
+-----------------------------------------------------------------------+

Name / General Description

Pool 1
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Pool 2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Pool 3
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Pool 4
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If more space is needed in any part of the form, please make a note and
use the back of the page.

1.  **PHYSICAL DESCRIPTION OF POOL**

+-------------+-------------+-------------+-------------+-------------+
|             | Pool 1      | Pool 2      | Pool 3      | Pool 4      |
+-------------+-------------+-------------+-------------+-------------+
| Indoor or   |             |             |             |             |
| Outdoor     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| General     |             |             |             |             |
| Shape       |             |             |             |             |
|             |             |             |             |             |
| (rectangle, |             |             |             |             |
| round..)    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Surface     |             |             |             |             |
| area        |             |             |             |             |
|             |             |             |             |             |
| (sq. ft. /  |             |             |             |             |
| m)          |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Length x    |             |             |             |             |
| Width (or   |             |             |             |             |
| Radius)     |             |             |             |             |
|             |             |             |             |             |
| (specify    |             |             |             |             |
| yds, ft or  |             |             |             |             |
| m)          |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| No. gallons |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Depth range |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| User        |             |             |             |             |
| Groups\*    |             |             |             |             |
|             |             |             |             |             |
| (i.e.       |             |             |             |             |
| daycare,    |             |             |             |             |
| swim teams, |             |             |             |             |
| water       |             |             |             |             |
| aerobics,   |             |             |             |             |
| adult swim  |             |             |             |             |
| etc.)       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Maximum     |             |             |             |             |
| bather load |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Decking     |             |             |             |             |
| type        |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Pool        |             |             |             |             |
| surface     |             |             |             |             |
| type        |             |             |             |             |
| (specify)   |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Slides      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Diving      |             |             |             |             |
| boards      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Sprinklers  |             |             |             |             |
| or other    |             |             |             |             |
| features    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Other       |             |             |             |             |
| Information |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

> \*In the space below, provide the age range, and the season/ month for
> each group using the pool.
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

What is the maximum bather load standard in your state for various
facilities and sizes?

Are their policies to ensure that bather load is not exceeded?

Does the pool(s) meet current design standards?

> 2\. WATER FLOW & TREATMENT

a.  WATER SOURCE

    What is the source of water used in the pool (i.e., natural, well,
    municipal, reclaimed, etc.)? What are the water treatment processes
    used in source water production?

b.  **STORAGE**

> Is the water stored on site under any condition (i.e. for future use)?
>
> **c. WATER FLOW / DELIVERY**
>
> How does the water flow from the pool(s), through the various (i.e.
> filtration, recirculation, heating, disinfecting) systems back into
> the pool?
>
> Explain the steps in the water flow process. (i.e. the water leaves
> the pool through the main drains -- x% enters through the heating
> system and then goes to the filtration system; y% goes directly
> through the filtration system -- the water then goes through the
> disinfection system---the water then enters the pool through the
> inlets)

Are the pipes labeled with the direction of the water flow?

Are the valves labeled with the direction of on/ off?

Are there any pipes with dead ends? If so, how are they capped off?

Are there any pipes where the water flow is not known?

How is the pool refilled?

> Does the water refilling the pool go through filtration? Disinfection?
> Heating? Recirculation? Other?

**Recirculation**

Fill in the number or description of the following and indicate their
locations on the diagram(s).

+-------------+-------------+-------------+-------------+-------------+
| Supply and  | Pool 1      | Pool 2      | Pool 3      | Pool 4      |
| return      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Fill Line   |             |             |             |             |
| Height (for |             |             |             |             |
| adding      |             |             |             |             |
| make-up     |             |             |             |             |
| water)      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Drains      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Skimmers    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Hair        |             |             |             |             |
| strainers   |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Return      |             |             |             |             |
| inlets      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Gutters     |             |             |             |             |
|             |             |             |             |             |
| (specify    |             |             |             |             |
| type)       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Other       |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Filtration**

  ---------------- -------------- -------------- -------------- --------------
  **Filter media** **Pool 1**     **Pool 2**     **Pool 3**     **Pool 4**

  Media type\*                                                  

  Make and model                                                

  Specifications                                                

  Surface area                                                  

  Maximum capacity                                              

  Gallons/ pound                                                
  or gallons/                                                   
  square inch                                                   

  Influent Gauge                                                
  reading                                                       

  Effluent Gauge                                                
  reading                                                       

  Slurry feeder                                                 
  ---------------- -------------- -------------- -------------- --------------

> \* DE, sand, gravity sand, pressure sand, anthracite, cartridge filter
> (specify media), other (specify).
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Please make sure to answer the following questions for all aquatic
facilities:**

> Is the pump size adequate to ensure the required turnover rate?
>
> Is the pump size adequate for the filter?
>
> Is the pump working near maximum capacity?
>
> In the event of an emergency, can the pump be made to work at a higher
> capacity than normal?
>
> Is the pump in good condition?

**If the pool has a cartridge filter, answer the following**

> Cartridges: give number, type, pore size (please specify unit of
> measure, i.e., microns).
>
> What is the maintenance routine?
>
> How old is it?
>
> What are the manufacturer's recommendations for cleaning the cartridge
> filter?
>
> Are the manufacturer's recommendations followed? If not, how is it
> cleaned?
>
> How often is it replaced?

**Filtration system**

  -------------- ------------- -------------- -------------- --------------
  **Sampling**   **Pool 1**    **Pool 2**     **Pool 3**     **Pool 4**

  Are there                                                  
  access ports                                               
  to sample                                                  
  media?                                                     

  Can backwashed                                             
  water be                                                   
  accessed for                                               
  sampling?                                                  

  Is the pool                                                
  filter                                                     
  accessible by                                              
  operator                                                   
  during                                                     
  operating                                                  
  hours?                                                     
  -------------- ------------- -------------- -------------- --------------

> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Turnover**

+---------------+-----------+-------------+-------------+-------------+
| **Turnover**  | **Pool    | **Pool 2**  | **Pool 3**  | **Pool 4**  |
|               | 1**       |             |             |             |
+---------------+-----------+-------------+-------------+-------------+
| Pump Make and |           |             |             |             |
| model         |           |             |             |             |
+---------------+-----------+-------------+-------------+-------------+
| S             |           |             |             |             |
| pecifications |           |             |             |             |
+---------------+-----------+-------------+-------------+-------------+
| Pump rate     |           |             |             |             |
+---------------+-----------+-------------+-------------+-------------+
| Flow rate     |           |             |             |             |
| (gpm)         |           |             |             |             |
+---------------+-----------+-------------+-------------+-------------+
| Turnover rate |           |             |             |             |
|               |           |             |             |             |
| (Required)    |           |             |             |             |
+---------------+-----------+-------------+-------------+-------------+
| Turnover rate |           |             |             |             |
| (Actual)      |           |             |             |             |
+---------------+-----------+-------------+-------------+-------------+
| Time since    |           |             |             |             |
| last          |           |             |             |             |
| maintenance   |           |             |             |             |
| date          |           |             |             |             |
+---------------+-----------+-------------+-------------+-------------+
| Volume of     |           |             |             |             |
| pool (gal)    |           |             |             |             |
+---------------+-----------+-------------+-------------+-------------+

> Turnover Rate = Pool Volume (in gallons)
>
> Pump Flow Rate (in gpm) \*60
>
> How many turnovers occur each day?
>
> (Indicate for each pool if there is more than one)
>
> Does the turnover rate of each pool meet the requirements?
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Backwash\***

> For what reasons do you backwash your pool (s) (pressure differential,
> water cloudy, etc.)?

  --------------- -------------- -------------- -------------- --------------
  **Backwash**    **Pool 1**     **Pool 2**     **Pool 3**     **Pool 4**

  How often?                                                   

  How long?                                                    

  Pressure                                                     
  differential                                                 
  needed before                                                
  backwash?\*\*                                                

  Where is it                                                  
  discharged?                                                  

  Is the backwash                                              
  visible?                                                     

  Other                                                        
  --------------- -------------- -------------- -------------- --------------

> \*Use back of page if necessary
>
> \*\*This information can be found in the pool's policy statement or
> manufacturer's manual
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> Are there exceptions to the backwash schedule for the pool(s)? If yes,
> what are the exceptions?

**Shared filtration**

Is shared filtration between pools allowed in your state/district?

> If there are multiple pools, are they on the same filter?
>
> If there is a kiddie pool, is it filtered separately? If not, which
> pool(s) does it cocirculate with? (kiddie pools are low volume,
> shallow wading pools catering to diaper and toddler-ages children and
> may be at higher risk for fecal contamination)

**Cross-connection**

> Is there an air gap where the fresh water enters the surge tank?
>
> Is there an air gap at the pool waste line/backwash line?
>
> Is there an air gap at the pool Fill line (used for adding make-up
> water)?

**Heater**

> **Note: heaters may inactivate certain pathogens therefore examining
> the temperature of the water in the boiler can help understand the
> health of the pool**
>
> Is (are) the pool(s) heated?
>
> Is there a thermometer to check and/or set the temperature of the
> water in the boiler?
>
> What is the high temperature in the boiler? (This information may be
> obtained from the operating manual.)
>
> What is the set point for pool temperature?
>
> System manufacturer and model? (This may be useful to obtain
> information such as high temperatures from the manufacturer if not
> otherwise available.)
>
> Temperature of water in return (based on the manufacturer's
> recommendations)?
>
> Is the water sent to the heater before filtration or after?
>
> What percentage of water is heated? (Approximately)
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Disinfection**

> Fill in the brand name and amount used. If UV is used, indicate the
> level of energy delivered in millijoules.

  --------------------- -------------- -------------- -------------- --------------
                        **Pool 1**     **Pool 2**     **Pool 3**     **Pool 4**

  Chlorine (specify                                                  
  liquid, tablet,                                                    
  powder, gas\*)                                                     

  Bromine                                                            

  Peroxyamino-sulfate                                                

  Ozone                                                              

  UV                                                                 

  Other                                                              
  --------------------- -------------- -------------- -------------- --------------

> \*If liquid chlorine, what % NaOCl (sodium hypochlorite) active
> ingredient?
>
> **\* In the following sections there are some questions regarding the
> distance between the controller and the probe. A smaller distance
> between these two is essential to ensure that actual pool conditions
> are being measured.**
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Disinfectant Addition**

  -------------- -------------- -------------- -------------- --------------
                 **Pool 1**     **Pool 2**     **Pool 3**     **Pool 4**

  Added manually                                              
  or by a                                                     
  controller?                                                 

  Name of system                                              
  or controller                                               

  Model                                                       

  Manufacturer                                                

  Distance from                                               
  the                                                         
  controller's                                                
  meter to the                                                
  probe                                                       

  Where is the                                                
  injector                                                    
  located?                                                    

  Distance from                                               
  chemical                                                    
  injection site                                              
  to probe                                                    
  -------------- -------------- -------------- -------------- --------------

If a controller is used, are colormetric tests being preformed, too?

> Does the automatic pool chlorinator measure chlorine or oxidation
> reduction potential (ORP)? If yes, what are the maintenance and
> calibration procedures and frequency of these? Is there an automatic
> record of these readings maintained?
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Disinfection policy**

> What is the response if chlorine levels drop too low?

**Cyanurates**

Is the use of cyanurates permitted in your state?

Are cyanurates used in these pool(s), specify?

> Do they factor in cyanurates with the measurement of free chlorine
> residual? If yes, how do they do it?
>
> What level of cyanurates is maintained?
>
> What are the state and local standards for pool chlorination? Do the
> standards account for cyanurates?
>
> If there is a state or local requirement to increase free chlorine ppm
> if cyanurates are present, does the pool conform?

Do they measure cyanurate levels? How often?

What method do you use to measure cyanurate levels?

**pH Adjustment Equipment**

  ---------------- ------------ -------------- -------------- --------------
                   **Pool 1**   **Pool 2**     **Pool 3**     **Pool 4**

  Type of                                                     
  chemicals used                                              
  for pH                                                      
  adjustment                                                  

  Added manually                                              
  or by a                                                     
  controller?                                                 

  Name of system                                              
  or controller                                               

  Model                                                       

  Manufacturer                                                

  Distance from                                               
  chemical                                                    
  injection site                                              
  to probe                                                    

  Where is the                                                
  injector                                                    
  located?                                                    

  Distance from                                               
  chemical                                                    
  injection site                                              
  to probe                                                    
  ---------------- ------------ -------------- -------------- --------------

> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Shocking the Pool(s) (hyperchlorination, superchlorination,
chlorine-shocking, etc.)**

> Under what conditions is the pool shocked?
>
> What method is used to shock the pool (specify products)?
>
> How is the proper amount of chemicals to use determined?
>
> If chlorine shock is used, what concentration (mg/L) is achieved?
>
> Do they measure the concentration? If yes, how?
>
> How do they return the disinfectant levels to normal?

**Waste**

> How is disposal of the following things handled?
>
> Chlorinated Water
>
> Where is chlorinated wastewater put?
>
> Does this meet the waste disposal standards?
>
> Wastes: old filter media, backwash
>
> **Biological Waste:**
>
> Vomit
>
> Fecal contamination
>
> Blood fluids
>
> Dead animals
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**3. ASSOCIATED PHYSICAL FACILITES**

**Hygiene**

> **Proper hand washing, especially after changing diapers or using the
> toilet is essential to reducing the risk of recreational water
> illnesses. This section addresses the ease of hand washing, showering,
> and other good hygiene practices in the facilities.**

  ----------------- ---------------- ---------------- ----------------------
  **Facility**      **Location**     **How many?**    **Distance from
                                                      pool\***

  Changing room                                       

  Toilet                                              

  Shower                                              

  Diaper-changing                                     
  area                                                

  Hand                                                
  washing/sinks                                       
  ----------------- ---------------- ---------------- ----------------------

> \*If more than one pool, specify distance from the nearest
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

What is the distance from the hand washing sinks to the diaper-changing
area?

Is there adequate soap, paper towels, hot water, etc.?

How often are supplies refilled?

Are directions for hand washing posted?

> Are the faucets spring-loaded? (Often spring loaded faucets do not
> give users enough time to adequately was their hands)

Is there a pre-swimming shower policy? If so, provide a copy or a
summary.

Is there a policy for washing hands? If so, provide a copy or a summary.

Are animals allowed on the premises? Is so, what types?

> Is there a swim diaper policy? If so, provide a copy or a summary.

**Food & Water Vending (If Applicable)**

> **Operation of Food & Water Vending**

Are there policies regarding food vending at this type of facility in
your state/district? If so, what are they?

> Is food service available? If so, list food source and type. Provide a
> list or menu of food served. What are the hours of operation?
>
> Are vending machines available? If so, list food source and type.
> Provide a list of food items.
>
> Is picnicking allowed at the pool facility? If so, where is picnicking
> allowed?
>
> Water fountain(s): how many? Where are they located?
>
> Are food and drink allowed around or in the pool?
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**4. FACILITY MANAGEMENT**

(If possible, obtain copies of all documents listed below.)

> **Operational**
>
> Is the pool public (i.e., municipal or other organization) or private
> (i.e., club or residential)? (Note: if these do not fit your state's
> categories, write them in)
>
> What are the months, hours and days of operation?
>
> What is the vacuuming schedule?
>
> **Biological Incident policy:**
>
> **Fecal accident response**
>
> Does the pool have a fecal accident response policy?
>
> If yes, what is the policy? (please obtain a written copy if possible)
>
> **Vomit response**
>
> Does the pool have a vomit response policy?

If yes, what is the vomit policy? (Please obtain a written copy if
possible)

**Blood-borne pathogen response**

Does the pool have a blood-borne pathogen response policy?

> If yes, what is the blood-borne pathogen policy? (Please obtain a
> written copy if possible)
>
> Is there a fecal/vomitus accident response log? If so, provide a copy.

**Record keeping**

Is the pool operator keeping water chemistry records?

What water chemistry activities are recorded in the log book?

How often and when are the water chemistry activities recorded in the
log book?

Who recorded the water chemistry measurements?

Is the acceptable range for water chemistry listed in the log book?

> Is the pool operator keeping maintenance records?
>
> What maintenance activities are recorded in the log book (backwash,
> etc.)?
>
> Are records kept of the following (if so, provide a copy):
>
> Construction or modifications
>
> Recent maintenance
>
> Pump & equipment repairs
>
> Disinfection system repairs
>
> Who reviews these records?
>
> What warrants a pool closing?
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**5. PEOPLE : Recreational Water Illnesses (RWIs) and Employees and Pool
users**

**Membership**

Is membership required?

If yes, what is the number of members?

**Ages**

What age groups are using pools?

**Policies**

What are the pool use policies (restrictions, limited use by certain
groups, etc.)

> What type of education of swimmers is there regarding RWIs (all
> swimmers, season-pass holders)?

What type of education required for pool staff regarding RWIs?

Is there a daycare use policy in place?

**Signage regarding policies on the following issues:**

Restrictions on swimmers?

Vomit?

> Fecal contamination?
>
> Blood fluids?
>
> Bather loads?
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**6. RECENT DEVELOPMENTS**

> Any recent pool problems that could lead to potential health effects
> (i.e. changes in filters, pumps, chemicals, etc.)? Describe.
>
> Has the pool switched any routines lately? Describe.
>
> Have there been any modifications to the pool lately? Describe.
>
> Has there been any disruption in the water service since opening the
> facility? Describe.
>
> Have fertilizers or pesticides been used near the pool recently?
> Describe.
>
> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**7. FIELD ASSESSMENT**

**Disinfection**

> **Field assessment measurements** (actual measurements on day of
> assessment)

+-------------+-------------+-------------+-------------+-------------+
|             | Pool 1      | Pool 2      | Pool 3      | Pool 4      |
+-------------+-------------+-------------+-------------+-------------+
| pH level    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Total       |             |             |             |             |
| chlorine    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Fr          |             |             |             |             |
| ee/residual |             |             |             |             |
| Cl~2~       |             |             |             |             |
| (normal)    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Combined    |             |             |             |             |
| chlorine    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| ORP reading |             |             |             |             |
|             |             |             |             |             |
| (if         |             |             |             |             |
| applicable) |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Total       |             |             |             |             |
| alkalinity  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Cyanurates  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Water       |             |             |             |             |
| clarity/    |             |             |             |             |
| Turbidity   |             |             |             |             |
| (e.g.       |             |             |             |             |
| visual or   |             |             |             |             |
| metric)     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> Water Chemistry Measurement Observations

+-------------------+---------+-----------+------------+-------------+
|                   | Pool 1  | Pool 2    | Pool 3     | Pool 4      |
+-------------------+---------+-----------+------------+-------------+
| Test kit          |         |           |            |             |
| manufacturer?     |         |           |            |             |
+-------------------+---------+-----------+------------+-------------+
| Expiration date   |         |           |            |             |
| of the chemicals  |         |           |            |             |
| in the test kit?  |         |           |            |             |
+-------------------+---------+-----------+------------+-------------+
| How often are     |         |           |            |             |
| free chlorine     |         |           |            |             |
| residual levels   |         |           |            |             |
| measured?         |         |           |            |             |
+-------------------+---------+-----------+------------+-------------+
| How often are the |         |           |            |             |
| pH levels         |         |           |            |             |
| measured?         |         |           |            |             |
+-------------------+---------+-----------+------------+-------------+
| What time(s) of   |         |           |            |             |
| day is the free   |         |           |            |             |
| chlorine          |         |           |            |             |
| measured?         |         |           |            |             |
|                   |         |           |            |             |
| The pH measured?  |         |           |            |             |
+-------------------+---------+-----------+------------+-------------+
| Method used for   |         |           |            |             |
| measurement?      |         |           |            |             |
|                   |         |           |            |             |
| (i.e., DPD)       |         |           |            |             |
+-------------------+---------+-----------+------------+-------------+
| Where is the      |         |           |            |             |
| reading taken?    |         |           |            |             |
|                   |         |           |            |             |
| (i.e., poolside,  |         |           |            |             |
| filter bay)       |         |           |            |             |
+-------------------+---------+-----------+------------+-------------+

> Notes:
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

What other water quality readings were taken and measurements?

If other water indicators measured, what method of measurement is used?

> What is the state/district policy regarding how often water chemistry
> readings should be taken?

How often are readings taken? Where are readings taken?

> **Notes:**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> *Final note to Environmental Health Specialist: if you think of any
> other situations or issues not covered by this form, please include
> them in this space.*
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
>
> Please attach plans or draw the pool(s), with measurements/dimensions
> indicated and/or provide labeled photographs, if possible.