Appendix E: Checklists and forms for Legionella bacteria control management program
- Legionella bacteria control management program-1: Facility checklist
- Legionella bacteria control management program-2: Contact list
- Legionella bacteria control management program-3: Legionella susceptible system inventory
- Legionella bacteria control management program-4: Testing form
- Legionella bacteria control management program-5: Chemical products and substances list
- Legionella bacteria control management program-6: System risk and hazard assessment form
Legionella bacteria control management program-1: Facility checklist
Facility information:
- Name:
- Address:
- Facility management entity:
- Facility manager:
- Date:
- Signature:
| Item | Action required | Guidance document(s) | Required form(s) | Completed (Y/N) |
|---|---|---|---|---|
| 1 | Identify and maintain an inventory of all Legionella susceptible water systems in the building. | MD 15161—2013 | LBCMP-3 | |
| 2 | Prepare a contact list that includes the facility manager, maintenance personnel, service contractors and equipment manufacturer representatives for each system identified in item 1 of this checklist. | MD 15161—2013 | LBCMP-2 | |
| 3 | Complete a risk and hazard assessment for each system identified in item 1 of this checklist. | MD 15161—2013 | LBCMP-6 | |
| 4 | Prepare a single line schematics of each system identified in item 1 of this checklist. Schematics are to be prepared and signed by a Professional Engineer. | MD 15161—2013 | N/A | |
| 5 | Identify all required maintenance checklists required for each system identified in item 1 of this checklist. | MD 15161—2013 | Refer to RPMS checklists | |
| 6 | Identify operation and maintenance manuals for each system identified in item 1 of this checklist. | MD 15161—2013 | N/A | |
| 7 | Identify the testing protocols required for each system identified in item 1 of this checklist. | MD 15161—2013 | Appendix D of MD 15161 | |
| 8 | Maintain a log of system testing and results for each system identified in item 1 of this checklist. | MD 15161—2013 | LBCMP-4 | |
| 9 | Maintain a list of all chemical products and substances used for the system identified in item 1 of this checklist. | MD 15161—2013 | LBCMP-5 | |
| 10 | Maintain hard copies and digital copies of items 1 through 9 at the facility. | MD 15161—2013 | N/A |
Applies to all Public Works and Government Services Canada (PWGSC) owned or operated facilities.
Legionella bacteria control management program-2: Contact list
Facility Information:
- Name:
- Address:
- Date:
- Signature:
This table is only an illustration and contains no data.
| Position/Responsability | Name (First, Last) | Employer | Telephone | ||
|---|---|---|---|---|---|
| Office | Cell | ||||
Instructions:
Provide contact information for facility manager, maintenance personnel, service contractors and equipment manufacturer representatives for all systems forming part of the facilities Legionella bacteria control management program.
Legionella bacteria control management program-3: Legionella susceptible system inventory
Facility information:
- Name:
- Address:
- Date:
- Signature:
This table is only an illustration and contains no data.
| System number | System type | System description | System risk level |
|---|---|---|---|
Instructions:
Complete an inventory of all Legionella susceptible systems present at the facility. These include cooling towers, open water systems (e.g., fountains, ponds), other water systems (e.g., domestic water systems, humidifiers, drain pans, whirlpools). Refer to MD 151612013 for additional information on Legionella susceptible systems.
- Facility risk level: Enter the facility's Legionella risk level (low/medium/high) based on Legionella risk level of the systems present. Refer to the Legionella Risk and Hazard Assessment section of MD 15161-2013 for guidance.
- System number: Enter the equipment identifier information.
- System type: Indicate the type of system (i.e., cooling tower, domestic hot water, domestic cold water, HVAC component, open water system).
- System description: Enter a description of the system (e.g., capacity, age, usage).
- System risk level: Enter the risk level (low/medium/high) for the system as determined by the system risk assessment (LBCMP-6).
Legionella bacteria control management program-4: Testing form
Facility information:
- Name:
- Address:
- System number:
- System type:
- System risk level:
- Date:
- Signature:
This table is only an illustration and contains no data.
| Sample date (yyyy/mm/dd) | Sampling location | Sampler | Test type | Testing results | Factors that may affect testing results | |
|---|---|---|---|---|---|---|
| Quantity | Units | |||||
Instructions:
Complete an inventory of all Legionella susceptible systems present at the facility. These include cooling towers, open water systems (e.g., fountains, ponds), other water systems (e.g., domestic water systems, humidifiers, drain pans, whirlpools). Refer to MD 15161-2013 for additional information on Legionella susceptible systems.
- System number: Enter the equipment tag number.
- System type: Enter the type of system (e.g., cooling tower, domestic water, humidifier, etc.)
- System risk level: Enter the risk level (low, medium, high) for the system as determined by the system risk assessment (LBCMP-6).
- Sample date: Enter the date the sample was taken.
- Sampling location: Indicate the location where the water sample was taken.
- Sampler: Indicate the name and organization of the person who took the sample.
- Test type: Indicate the type of test (dipslide, culture, pcr, residual oxidant).
Legionella bacteria control management program-5: Chemical products and substances list
Facility information:
- Name:
- Address:
- Date:
- Signature:
This table is only an illustration and contains no data.
| Item | Product name | Product type | Product manufacturer | Systems using the product |
|---|---|---|---|---|
| 1 | ||||
| 2 | ||||
| 3 | ||||
| 4 | ||||
| 5 | ||||
| 6 | ||||
| 7 | ||||
| 8 | ||||
| 9 | ||||
| 10 | ||||
| 11 | ||||
| 12 | ||||
| 13 | ||||
| 14 | ||||
| 15 | ||||
| 16 | ||||
| 17 |
Instructions:
Complete an inventory of all chemical products and substances used to control bacterial growth or water quality in the legionella susceptible systems located at the facility.
- Product name: Indicate the name of the product.
- Product type: Indicate the type of product (chemical, biocide, etc.).
- Product manufacturer: Indicate the name of the manufacturer of the product.
- System using the product: Indicate the system(s) in the facility where this product is used.
Legionella bacteria control management program-6: System risk and hazard assessment form
Facility information:
- Name:
- Address:
- System number:
- System type:
- System risk level:
- Date:
- Signature:
This table is only an illustration and contains no data.
| Hazard number | System Legionella hazard characteristics | Characteristic risk level |
|---|---|---|
| 1 | ||
| 2 | ||
| 3 | ||
| 4 | ||
| 5 | ||
| 6 | ||
| 7 | ||
| 10 | ||
| 11 | ||
| 12 | ||
| 13 | ||
| 14 | ||
| 15 |
Instructions:
Complete a Hazard and Risk Assessment of all Legionella susceptable systems present at the facility. These include cooling towers, open water systems (e.g., fountains, ponds) other water systems (e.g., domestic water systems, humidifiers, drain pans, whirlpools). Refer to MD 15161-2013 for additional information on Legionella susceptible systems and the Risk and Hazard Assessment Requirements.
- System number: Enter the Equipment Tag Number.
- System type: Enter the type of system (e.g., cooling tower, domestic water, humidifier, etc.).
- System risk level: Enter the risk level for highest (high, medium, low) Legionella hazard characteristic identified.
- System Legionella hazard characteristics: Identify and describe the characteristics of the system that pose a Legionella Hazard. Refer to the Legionella Risk and Hazard Assessment Section of MD 15161-2013 for guidance.
- Characteristic risk level: Enter the risk level (high, medium, low) for each Legionella hazard characteristic.
- Date modified: