facility assessment form Facility Assessment Form Get an assessment of your facility? Thank you for your interest in SPL, we will be in contact with you shortly. FACILITY INFORMATIONFacility Name* Type of Facility Apartment Hospitality Education Healthcare Industrial Long-Term Care Office Other Facility Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact Name* First Last Title YOUR INFORMATIONOrganization* PhoneEmail FaxAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Any Confirmed Cases of Legionnaires' Disease in facility?* Yes No If yes, provide detailsWater treatment Provider?* No Cooling Tower Potable Other Name of company and water treatment providerEnvironmental surveillance for Legionella in water systems?* No Cooling Tower Potable Other BUILDING INFORMATION(Enter Max. 10 Buildings)BUILDING INFORMATIONBuilding NameBuilding Use# of Floors# Occupants or BedsEnter # of Systems Per Building(0-10)Cooling TowerPool or SpaDecor Water FeatureOther Aerosol GeneratingPotable Cold WaterPotable Hot WaterPotable Supplemental Disinfection (Choose type of technology)NoneChlorineChlorine DioxideCu/Ag IonizationMonochloramineEnter Another Building? Yes BUILDING INFORMATION #2Building NameBuilding Use# of Floors# Occupants or BedsEnter # of Systems Per Building(0-5)Cooling TowerPool or SpaDecor Water FeatureOther Aerosol GeneratingPotable Cold WaterPotable Hot WaterPotable Supplemental Disinfection (Choose type of technology)NoneChlorineChlorine DioxideCu/Ag IonizationMonochloramineEnter Another Building? Yes BUILDING INFORMATION #3Building NameBuilding Use# of Floors# Occupants or BedsEnter # of Systems Per Building(0-5)Cooling TowerPool or SpaDecor Water FeatureOther Aerosol GeneratingPotable Cold WaterPotable Hot WaterPotable Supplemental Disinfection (Choose type of technology)NoneChlorineChlorine DioxideCu/Ag IonizationMonochloramineEnter Another Building? Yes BUILDING INFORMATION #4Building NameBuilding Use# of Floors# Occupants or BedsEnter # of Systems Per Building(0-5)Cooling TowerPool or SpaDecor Water FeatureOther Aerosol GeneratingPotable Cold WaterPotable Hot WaterPotable Supplemental Disinfection (Choose type of technology)NoneChlorineChlorine DioxideCu/Ag IonizationMonochloramineEnter Another Building? Yes Δ
