Pre Assesment Form Legionella Risk Assessment Pre-Assessment Form 1. Premises Details Full Address & business name if you are a business Postcode Main Contact Telephone Email Address Client Name (for report, certificate & invoice) 2. Duty Holder Details Name of Duty Holder 3. Responsible Person Name of Responsible Person 4. Premises Use & Occupancy Type of Premises Surgery Children’s Nursery Pre-school Day Care School Entertainment Venue Office Factory Other If other, please specify 5. System Use & Management Are all areas used daily? — Please choose — Yes No Unused / rarely used areas Flushing regime in place? — Please choose — Yes No Unsure Recent plumbing changes? — Please choose — Yes No If yes, details 6. Previous Legionella Management Previous assessment? — Please choose — Yes No Unsure Date of last assessment Logbook kept? — Please choose — Yes No Unsure Data Protection We will use the information you provide to arrange and carry out your Legionella risk assessment and related services. Your data will be handled in accordance with our Privacy Policy. View our Privacy Policy I confirm I have read and agree to the Privacy Policy. Submit Form
