007.04.3 Appendix F. Record of Pool Contamination Incident
AR ADC 007.04.3 Appendix FArkansas Administrative Code
Ark. Admin. Code 007.04.3 Appendix F
007.04.3 Appendix F. Record of Pool Contamination Incident
Date of incident: ______________________________ Time of incident: _________________________
Name of individual responsible for incident: ________________________________________
Home Address: ___________________________________ Male __________ Female __________
City, AR, Zip: ______________________________ Phone: ______________________________
Did individual have any symptoms of illness at the time of incident? Yes __________ No __________
If yes, list the symptoms: _____________________________________________
Nature of incident: | _____ Formed stool | _____ Diarrhea |
_____ Vomitus | _____ Blood |
Time of pool closure: _____ AM/PM
______________________________ | Is person in charge CPO certified? |
Name of person in charge at the time of the incident | _____ Yes _____ No |
Pool chemical readings at time of incident: Free Chlorine __________ Combined Chlorine __________
Total Alkalinity __________ Cyanuric Acid __________ pH __________
Describe corrective action taken in sequence:
Specify chemical adjustments made:
Pool chemical readings at time of re-opening: Free Chlorine __________ Combined Chlorine __________
Total Alkalinity __________ Cyanuric Acid __________ pH __________
Time of re-testing: __________ AM/PM Time pool was reopened: __________ AM/PM
___________________________________ | _______________ |
Print Name / Title | Date |
___________________________________
Signature of person completing report
Was matter reported to local health department? __________ Yes __________ No
Retain with permanent facility records
Credits
Adopted Aug. 1, 2012.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 007.04.3 Appendix F, AR ADC 007.04.3 Appendix F
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