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Legionella Risk Assessment — Cover
Section 1

Assessment Information

Form — complete all fields
Document Reference
Date of Assessment
Client / Managing Agent
Property Address (Door No. & Street)
Postcode
Type of Dwelling
Occupancy
Vulnerable Occupants?
Assessor
Suggested Review Date
Section 2

Water System Details

Supply, heating & distribution
Cold Water Supply
Hot Water Generation
Last Use of System
Section 3

System Inspection

HSG 274 Part 2 — visual checks
# Audit point Status Observation
Cold-water storage tank covered, insulated and vermin-proof.
Cold-water storage tank free of debris, scale, biofilm or stagnation.
Cold and hot pipework adequately insulated; cold separated from heat sources.
No visible dead legs, redundant pipework or capped spurs.
Hot water cylinder in good condition; no leaks at fittings.
All outlets are in regular use (at least weekly) — or flushing regime in place.
Shower head and hose free of visible scale, biofilm or damage.
No flexible hose connections that could permit back-flow / stagnation.
Thermostatic mixing valves (TMVs) accessible and identified.
Section 4

Temperature Monitoring

Sentinel readings (HSG 274 Part 2)
# Outlet Target Reading °C Time to reach Status
Section 5

Photographic Evidence

Supporting images
No photos yet
Section 6

Action Plan

Items requiring follow-up
# Action required Risk Responsible Target
Section 7

Executive Summary

Overall legionella risk
Overall Risk
Items flagged
0
Actions required
0
Assessment date
Next review
Section 8

Declaration & Sign-off

Issued by & acknowledged

8.1   Assessor

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Legionella Risk Assessment