[Environmental Health Outbreak Investigation Report:]{.underline}

[Swimming Pool Venue]{.underline}

*Note to inspector: This inspection form is designed to be used to
investigate a pool or pools that are suspected or confirmed as being
involved in an outbreak of a recreational waterborne illness. It is not
meant to be used on routine inspections. It should cover most relevant
environmental health threats at the swimming pool venue, not only
fecal-oral transmission via the pool water. Other modes of transmission
may include person-to-person, foodborne or contamination from
neighboring properties.*

*Where applicable, specify the unit of measurement being used (e.g.,
meters vs. feet).*

*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. If there is
more than one pool, specify whether answers apply to both pools or just
one. Also specify whether the pool is indoor or outdoor, child or
adult.*

*If there is more than one pool, provide here a brief descriptive name
for each, e.g., adult indoor, child outdoor, etc. Throughout this form
the pools will simply be referred to as Pool 1, Pool 2, etc. This form
does not include space for more than four pools. Use multiple forms if
more pools are included (e.g., at a waterpark).*

*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. DESCRIPTION OF POOL(S)**

If available, please attach a plan review diagram to this report. 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, or
attach a photograph.

**Physical description**

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

  **Surface area                                              
  (sq. ft.)**                                                 

  **No.                                                       
  gallons**                                                   

  **Depth                                                     
  range**                                                     

  **Bather                                                    
  load**                                                      

  **Other**                                                   
  -------------- -------------- -------------- -------------- --------------

**Water Source**

What is the source of pool water (i.e., municipal, reclaimed, etc.)?

**Fencing**

If outdoor pool, is there a fence?

If so, answer the following:

> Is it entirely fenced or just partially?
>
> How high is the fence? Is it within code?
>
> Are the gates kept locked during off-hours?
>
> Are there any other openings through which animals or small children
> can crawl?

**Fill in the number of the following and indicate their locations on
the last page.**

  -------------- -------------- -------------- -------------- --------------
  **Supply and   **Pool 1**     **Pool 2**     **Pool 3**     **Pool 4**
  return**                                                    

  **Inlets**                                                  

  **Drains**                                                  

  **Skimmers**                                                

  **Returns**                                                 

  **Other**                                                   
  -------------- -------------- -------------- -------------- --------------

**Fill in the number of the following and indicate their locations on
the last page.**

+-------------+-------------+-------------+-------------+-------------+
| **          | **Pool 1**  | **Pool 2**  | **Pool 3**  | **Pool 4**  |
| Structure** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Slides**  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Diving    |             |             |             |             |
| boards**    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| *           |             |             |             |             |
| *Sprinklers |             |             |             |             |
| or other    |             |             |             |             |
| features**  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Other\*** |             |             |             |             |
|             |             |             |             |             |
| **(         |             |             |             |             |
| describe)** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

**\* draw picture or include photograph on last page**

**2. 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

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

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

How often are supplies refilled?

Are directions for handwashing posted?

Are the faucets spring-loaded? (This may be a problem if it makes it
more difficult to wash hands thoroughly.)

**Food and drink**

**Note: this information can help to determine if foodborne or
waterborne (drinking or recreational) transmission was involved in the
outbreak.**

Is food service available? If so, list food source and type. Provide a
list or menu of food served.

Water fountain(s): how many? Where are they located?

Are food and drink allowed around or in the pool?

What are the hours of operation?

**3. POOL OPERATION**

**Heating**

**Note: heaters may inactivate certain pathogens**

Is (are) the pool(s) heated? (if no, skip to filtration section below)

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?

Is the water sent to the heater before filtration or after?

**Filtration**

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

  **Media type\***                                                  

  **Make and model**                                                

  **Specifications**                                                

  **Surface area and                                                
  capacity**                                                        
  -------------------- -------------- -------------- -------------- --------------

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

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

> Cartridges: give number, type, pore size (please specify unit of
> measure, i.e., microns).
>
> How is it cleaned?
>
> What is the maintenance routine?
>
> How old is it?
>
> What are the manufacturer's recommendations for cleaning?
>
> 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?**                                                    
  -------------- -------------- -------------- -------------- --------------

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

  **Turnover                                                  
  rate**                                                      

  **Pump speed**                                              

  **Flow rate**                                               
  -------------- -------------- -------------- -------------- --------------

**Backwash\***

  ----------------- -------------- -------------- -------------- --------------
  **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?**                                                     

  **When do                                                      
  operators diverge                                              
  from schedule?**                                               

  **Other**                                                      
  ----------------- -------------- -------------- -------------- --------------

\*use back of page if necessary

\*\*This information can be found in the pool's policy statement or
manufacturer's manual

**Shared filtration**

> If there are multiple pools, are they on the same filter?
>
> If there is a kiddie pool, is it filtered separately? If not, which
> pools does it cocirculate with?

**Cross-connection**

Is there an airgap where the fresh water enters the collection tank?

Is there an airgap at the pool waste line/backwash line?

**Disinfection**

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

+-------------+-------------+-------------+-------------+-------------+
| **Mea       | **Pool 1**  | **Pool 2**  | **Pool 3**  | **Pool 4**  |
| surements** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **pH        |             |             |             |             |
| level**     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Total     |             |             |             |             |
| chlorine**  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Fr        |             |             |             |             |
| ee/residual |             |             |             |             |
| Cl~2~       |             |             |             |             |
| (normal)**  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **ORP       |             |             |             |             |
| reading**   |             |             |             |             |
|             |             |             |             |             |
| **(if       |             |             |             |             |
| ap          |             |             |             |             |
| plicable)** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Total     |             |             |             |             |
| a           |             |             |             |             |
| lkalinity** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **C         |             |             |             |             |
| yanurates** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

+-------------+-------------+-------------+-------------+-------------+
| **Cl        | **Pool 1**  | **Pool 2**  | **Pool 3**  | **Pool 4**  |
| Me          |             |             |             |             |
| asurement** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Test kit  |             |             |             |             |
| manu        |             |             |             |             |
| facturer?** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **How often |             |             |             |             |
| are free    |             |             |             |             |
| chlorine    |             |             |             |             |
| residual    |             |             |             |             |
| levels      |             |             |             |             |
| measured?** |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Method    |             |             |             |             |
| used for    |             |             |             |             |
| mea         |             |             |             |             |
| surement?** |             |             |             |             |
|             |             |             |             |             |
| **(i.e.,    |             |             |             |             |
| DPD)**      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| **Where is  |             |             |             |             |
| the reading |             |             |             |             |
| taken?**    |             |             |             |             |
|             |             |             |             |             |
| **(i.e.,    |             |             |             |             |
| poolside,   |             |             |             |             |
| filter      |             |             |             |             |
| bay)**      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

  ---------------- -------------- -------------- -------------- --------------
  **Disinfectant   **Pool 1**     **Pool 2**     **Pool 3**     **Pool 4**
  addition**                                                    

  **Type of                                                     
  chlorine:                                                     
  liquid, tablet,                                               
  powder, gas?\***                                              

  **Added manually                                              
  or automated?**                                               

  **Distance from                                               
  disinfectant                                                  
  injector to                                                   
  pool?**                                                       
  ---------------- -------------- -------------- -------------- --------------

\*If liquid chlorine, what % NaOCl (sodium hypochlorite) active
ingredient?

**If disinfectant is automated, answer the following**

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

  **Name of system                                                
  or controller**                                                 

  **Model**                                                       

  **Manufacturer**                                                
  ------------------ -------------- -------------- -------------- --------------

Does the automatic pool chlorinator measure chlorine or oxidation
reduction potential (ORP)?

**Cyanurates** (if none, skip this section)

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?

**Hyperchlorination (a.k.a. superchlorination or chlorine-shocking)**

> How is it done? (i.e., What are the chemicals being used? What amounts
> used? Length of time?)
>
> What concentration (mg/L) is achieved?
>
> Do they measure the concentration? If yes, how?
>
> How do they return the disinfectant levels to normal?
>
> Is hyperchlorination accompanied by disinfecting diaper-changing
> areas, etc?

**Additional disinfectants and systems**

If other disinfectants are added, use the following table. Fill in the
brand name and amount used.

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

  **Bromine**                                                            

  **Peroxyamino-sulfate**                                                

  **Other**                                                              
  ------------------------- -------------- -------------- -------------- --------------

Is another disinfectant system used? (Y or N)

If yes, use the following table. If a pool uses one of the following
additional disinfectant systems, write the brand name and amount used.
If UV is used, indicate the level of energy delivered.

  ---------------- -------------- -------------- -------------- --------------
  **Disinfectant   **Pool 1**     **Pool 2**     **Pool 3**     **Pool 4**
  system**                                                      

  **Ozone**                                                     

  **UV**                                                        

  **Other**                                                     
  ---------------- -------------- -------------- -------------- --------------

**4. POLICIES, RECORDS, AND OPERATIONAL PARAMETERS**

(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 hours of operation?
>
> What is the vacuuming schedule?

**Water quality policy (what does the pool require of staff?)**

> Cl~2~
>
> pH

**Accident response policy:**

> Fecal accident response
>
> Vomit response
>
> Is there a fecal/vomitus accident response log? If so, provide a copy.

**Record keeping**

Is the pool operator keeping maintenance records?

What maintenance activities are recorded in the log book?

Are records kept of the following (if so, provide a copy)

> Construction or modifications
>
> Recent maintenance
>
> Pump repairs
>
> Chlorinator repairs

What warrants a pool closing?

**Hygiene**

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?

**Disinfection policy**

What is the response if chlorine levels drop too low?

**Personnel**

**Note: all employee job categories should be included. This may help
determine whether a study of employee illness would be desirable or
feasible.**

List number of employees and their duties. (use back of page if
necessary)

Number of shifts?

Number of employees of each type per shift?

What is the policy for use of swim facilities by off-duty staff?

Consecutive minutes that lifeguards are on duty?

Lifeguards per \# of bathers?

Does the state or local health department require training for pool
operator management positions? \[e.g., Certified Pool Operator (CPO),
Aquatic Facility Operator (AFO), or equivalent?\]

Is there a CPO/AFO or equivalent requirement by the pool?

Who among the staff is a CPO/AFO or equivalent?

**Membership**

Number of members

Provide lists of the following:

> Groups that use pool (categorize by age range)
>
> Outside visitors
>
> Rental groups
>
> Swim teams and/or leagues that use a variety of pools. Where else do
> these groups swim?

**5. RECENT DEVELOPMENTS**

Any recent pool problems leading up to the outbreak? 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?
Describe.

**6. NEIGHBORING PROPERTIES OF NOTE**

(Provide the name and location)

Farmland

Playgrounds

Day care centers

Zoos

Wildlife areas

Other recreational water venues, i.e., lakes, rivers, etc.

Are there drainage problems that could impact the pool?

Final note to inspector: if you think of any other situations or issues
not covered by this form, please include them in this space.

Please draw the pool, with measurements/dimensions indicated. \[provide
photograph if possible\]