CBI INTELLIGENCE Assessment Details Facility Name Date of Assessment Street Address City State Zip Person(s) Completing the Assessment Name Job Title Organization Telephone E-mail Person(s) Interviewed Name Job Title Organization Telephone E-mail Facility Characteristics Is this a healthcare facility or facility with skilled nursing care? Yes (Complete Appendix A) No If No, check all applicable: Other residential Hotel/motel/resort Vacation rental Recreational facility Office building Manufacturing facility Restaurant Other Total number of buildings on the premises Total number of buildings being assessed Total number of rooms that can be occupied overnight Does occupancy vary throughout the year? Yes No If Yes, seasons with lowest occupancy: Winter Spring Summer Fall Are any occupant rooms taken out of service? Yes No If Yes, which rooms? Did the facility recently experience a period of prolonged, reduced occupancy? Yes No If Yes, which rooms/buildings? Describe interventions for occupancy changes Average length of stay 1 night 2–3 nights 4–7 nights >7 nights Does the facility have emergency water systems? Yes No If Yes, are they regularly tested? Yes No If Yes, how often and when was the last test? Are there any cooling towers or evaporative condensers? Yes (Complete Appendix B) No Are there any hot tubs, whirlpool spas, or hydrotherapy spas? Yes (Complete Appendix C) No Are there any decorative fountains, misters, water features? Yes (Complete Appendix D) No Does the facility have centralized humidification or room humidifiers? Yes No If Yes, describe location and operation Does the facility have ice machines? Yes No If Yes, list manufacturer and model Does the facility have a landscape irrigation or sprinkler system? Yes No If Yes, describe location and operation Has there been any recent or ongoing major construction? Yes (Complete Appendix E) No Has this facility been associated with a previous legionellosis cluster or outbreak? Yes No If Yes, describe cases, dates, sources, interventions Does the facility have a water management program (WMP)? Yes No If Yes, does it test for Legionella? Yes No If Yes, describe program (including surveillance) Building Information Building Name Original Construction Year Later Construction (From/To) Stories/Levels Occupancy Rate (%) Daily Census (avg) Use Comments Water Supply Source What is the source of the water? Public water system Name of supplier How is the municipal water disinfected? Chlorine Monochloramine Other Has treatment changed in the past year? Yes No If Yes, specify Private well How is the well water disinfected? Chlorine Other Not disinfected Is the water filtered on site? Yes No Other Have there been any pressure drops, boil water advisories, or water disruptions in the past 6 months? Yes No If Yes, describe Does the facility monitor incoming water parameters? Yes No If Yes, what is the range of disinfectant residual, temperature, and pH on the day of assessment Premise Plumbing System Are cisterns and/or water storage holding tanks used? Yes No Are water softeners used? Yes No If Yes, installed on hot, cold, or both? Are water filters used? Yes No If Yes, installed centrally or at points of use Filter type and manufacturer/model Is there a recirculation system for hot water? Yes No If Yes, describe where it runs and temperatures Are thermostatic mixing valves used? Yes No If Yes, describe location Temperature set point(s) Hot Water System Configuration Building Name Type of System Name of System Areas Served Date of Installation Total Capacity (gallons) Usual Temperature (°F) Distal Outlet Temperature (°F) What is the maximum hot water temperature at delivery permitted by regulations? (°F or °C) Are hot water temperatures measured at points of use? Yes No If Yes, lowest documented hot water temperature (°F or °C) Documented on Are cold water temperatures measured at points of use? Yes No If Yes, highest documented cold water temperature (°F or °C) Documented on Typical cold water temperature in summer (°F or °C) Are potable water disinfectant levels measured at points of use? Yes No If Yes, how often Range of residuals (Summer) Range of residuals (Winter) Does the facility have a supplemental disinfection system? Yes No Describe any maintenance activities on the potable water system in the past year Measured Water System Parameters Building Name Name of System Part of System (C/P/D) Sampling Site Free Chlorine (ppm) Monochloramine (ppm) pH Temp (°F) Time to Max Temp (min) Comments Appendix A: Healthcare, Assisted Living, and Senior Living Facilities Type of healthcare facility (check all that apply) Acute care hospital Has transplant program? Yes No Long-term care facility Rehabilitation facility Assisted living Senior living Outpatient surgical center Other outpatient clinic Other Number of beds Are ice machines used for patient consumption or equipment? Yes No If Yes, list manufacturer and model Do patients use respiratory therapy equipment? Yes No If Yes, describe Has this facility experienced previous Legionnaires’ disease cases? Yes No If Yes, describe Appendix B: Cooling Towers and Evaporative Condensers Cooling Tower Details Cooling Tower ID Operational (Y/N) Manufacturer Date of Installation Location Number of Cells Drift Eliminators (Y/N) Purpose Disinfectant used in cooling tower(s)? Yes No If Yes, type of disinfectant? Oxidizing Yes No Non-oxidizing Yes No List name(s) of disinfectant used Specific Parameters Cooling Tower ID Current Disinfectant Level Current Water Temperature Current Water pH CDC Legionella Prevention Tips An effective water management program is the primary strategy to control Legionella growth and spread. Maintain appropriate water temperature and disinfectant levels. Monitor and maintain adequate disinfectant levels in hot tubs (3–10 ppm free chlorine or 4–8 ppm bromine, pH 7.2–7.8). Flush faucets and showerheads if not used for a week or more. Clean and maintain all fountains according to manufacturer recommendations. Follow local, state, territorial, federal, or tribal laws for water management. If concerned about Legionella, test water samples and disinfect systems. OSHA Water Safety Checklist for Legionella Conduct visual inspections and maintenance to prevent scale, sediment, and biofouling. Maintain records of system descriptions, operating procedures, inspection/cleaning/disinfection dates, test results. Use biocides like chlorine, bromine, ozone for control. Provide PPE for maintenance: gloves, goggles, respirators (N95 or better). For cooling towers: Clean/disinfect twice yearly, use high-efficiency drift eliminators. For hot water systems: Store at ≥140°F, deliver at ≥122°F, flush lines, clean aerators. For cold water systems: Limit storage, eliminate stagnant tanks, use backflow preventers. For HVAC: Drain sumps, clean routinely, locate intakes away from cooling towers. Train on PPE use and limitations. Comments and Summary Comments Summary Upload Files Attach photos, logs, reports, etc. Export as PDF Report