Guide to Produce Farm Investigations, November 2005

508 Narrative for Attachments 5-11, which are copies of forms from Procedures to Investigate Waterborne Illness, Second Edition 1996. Copyright held by the International Association for Food Protection (IAFP), Des Moines, Iowa, USA

Attachment 5 - Form G1
Illustration of Contamination Flow
Diagram defective portion of water supply system and illustrate sources of pollution and their likely entrance into the system. (Specify gradients and pressure differentials that altered flow.)

Complaint number:

44 by 55 square grid provided for illustration of contamination flow.  Scale: 1 block =

Investigator	
Title:
Agency:
Date:

Attachment 6- Form G2
Record Review of On-site Investigations and Test Results Prior to and During Outbreak (Data from on-site record review and Forms F and G) – Form G2

Complaint number:

Heterotrophic Plate Count (HPC)
Location, Date, Result

Fecal Coliform Counts (raw/plant/distribution)
Location, Date, Result

Other Chemical Tests (e.g., Chlorine demand of raw supply)
Location, Date, Result

Total Coliform Count (raw water)
Location, Date, Result

Other Microbiological Tests (specify)
Location, Date, Result

Physical/Organoleptic Tests (pH, turbidity, jar)
Location, Date, Result

Total Coliform Count (finished)
Location, Date, Result

Chlorine Residuals (plant)
Location, Date, Result (checkboxes: Free, Total)

Total Coliform Count (distribution)
Location, Date, Result

Chlorine Residuals (distribution)
Location, Date, Result (checkboxes: Free, Total)

Other Examinations
Specify, Date, Result

Interpretations:

Reviewer:
Title:
Date:

Attachment 7- Form G3
Source and Mode of Contamination of Surface Waters (Footnote: Note all that apply. Explain source/mode of contamination and describe entry in more detail on back or on separate attached sheet.)

Complaint Number:
Name of surface supply:
Location:
Person-in-charge
Phone:

Land Use of Watershed (Checkboxes: Cultivated, Forested, Irrigated, Oil fields, Recreation, Feedlot, Industrial, Mining, Pasture, Thickly settled, Other (describe))

Recent (Checkboxes: Flooding, Drought)

Dates

Type Sewage for Populated Areas (Checkboxes: Primary, Secondary, Oxidation pond, Septic tanks, Untreated/raw, Others (describe))

Discharges into Surface Water (Yes/No checkboxes for each type of sewage listed above)

Types of Animals in Watershed (Checkboxes: Livestock, Poultry, Aquatic mammals, Waterfowl, Snails, Others (list)

Sewage outfalls or seepage into source water (give location and distance from water intake or point of use)

Source of pollution (give location and distance from intake or point of use) (Checkboxes: Sewage, Industrial waste, Mining waste, Landfill leachate, Outfalls/seepage into source water, Feedlot, Slaughterhouse, Pasture runoff into surface water)

Results of dye test from outlets or seepage to intake or point of use or other means of evaluation of movement of contaminants

Results of any physical/chemical/microbial test of source water (see Form G2)

Factors contributing to surface water pollution/contamination and outbreak (Footnote: Record on Form L) [Checkboxes: Ingestion of untreated water, Pollution of watershed, Use of contaminated water as alternate source, Overflow of sewage or outfall near water intake, Drought, Flooding, Dead animal in water, Animals have direct access to water, Other (specify]

Investigator:
Title:

Agency:
Date:

Attachment 8- Form G4
Source and Mode of Contamination of Ground Waters (Footnote: Note all that apply. Explain source/mode of contamination and describe entry in more detail on back or on separate attached sheet.)

Complaint Number
Location:
Person-in-charge/Owner:
Phone:

Type of Ground Supply (Checkboxes: Well, Spring, Other (specify))
State source of information:

Type of Well (Checkboxes: Drilled, Bored, Driven, Dug, Step, Other)
State source of information:

Type of Soil and Aquifer (Checkboxes: Sand, Clay, Loam, Peat, Gravel, Rocky, Limestone, Other (specify))
State source of information:

Depth (Sub-headings: Static water, Well)
State source of information:

Excreta disposal in vicinity of well which may have contaminated the ground water:

Type: (Checkboxes: Community primary, Community secondary, Leaking sewer line, Septic tank, Cesspool/seepage pit, Absorption field, Privy, Toxic waste disposal
Distance:

Type: (Checkboxes: Stream, Surface water, Animals, Feedlot, Manure piles, Compost, Dump/landfill, Toxic waste storage
Distance:

Observed faults in construction/maintenance/operation of well/springs/other ground water sources:

Checkbox: Casing
Depth

Checkbox: Grouted casing
Depth

Additional Checkboxes: Casing not intact, Animal holes around casing, Platform/apron not intact, Pitless adapter faulty, Open well/spring, Flooding, Casing tip below grade, Other (specify)

Type pump: (Checkboxes: Submersible, Jet, Turbine, Reciprocating, Hand, Gravity, Other (specify))

Source of priming water:

Disinfection (Checkboxes: None, Failure)
Chlorine Test (Checkboxes: Free, Total)

Contamination during pumping: (Checkboxes: Unsafe water for priming, Leaks in system under vacuum, Well pit flooded, Pump not sealed to platform/top bushing not closed, Other (specify))

Type repairs made:
Disinfection following repairs: (Checkboxes: Yes, No)
Date:

Results of dye test from outlets or seepage to intake or point of use or other means of evaluation of movement of contaminants

Results of any physical/chemical/microbial test of ground water (give test done, dates, present/absent/count/concentration, as applicable; see Form G2)

Factors contributing to ground water contamination and outbreak (Footnote: Record on Form L): (Checkboxes: Overflow or seepage of sewage into well/spring, Surface runoff into well/spring, Contamination through limestone or fissured rock, Flooding/heavy rains, Chemical/pesticide contamination, Seepage from abandoned well, Contamination through suction line, Improper well/spring construction, Unsafe water used for priming, Other (specify)

Investigator:
Title:
Agency:
Date:

Attachment 9- Form G5a
Disinfection Failures that Allowed Survival of Pathogens or Toxic Substances (Footnote: Explain treatment failure and describe entry in more detail on back or on separate sheet.)

Complaint Number:
Name of Facility:
Location:
Person-in-Charge:
Phone:

Type disinfection: [Checkboxes: None, Simple chlorination, Super chlorination, Breakpoint chlorination, Ultraviolet, Hypochlorite, Chloramines, Chlorine dioxide, Ozone, Other (specify)]

Deficiencies in: (Checkboxes: Disinfection equipment, Disinfection operation, Chlorine contact time)
Dates:

Interruptions in: (Checkboxes: Disinfection equipment, Disinfection operation)
Dates:

Comments
Chlorine demand

Disinfection tests at plant (give minimum values)

Location

During investigation:
Free:
Total:


Day before:
Free:
Total:

2 days before:
Free:
Total:

Last week (date):
Free:
Total:

Last month (date):
Free:
Total:

Comments:

Disinfection rate applied = disinfectant used per day / flow rate

Disinfectant demand (usage) = disinfectant dosage applied – disinfectant concentration measured downstream

Checkbox: Sudden changes in disinfectant demand, if yes, date(s)

Columnar chart:
Top row: Disinfectant concentration C (mg/L), Disinfectant contact time T (minutes), CT calc C x T, pH, Water temperature (degrees Celsius), CT 99.9 (from Table H), CT Calc / CT 99.9

Left column: Sequence 1st, 2nd, 3rd, 4th, 5th, Sum

Factors contributing to survival of pathogen or failure of inactivation of toxin during treatment and outbreak (Footnote: Record on Form L)

Checkboxes: Inadequate prefiltration treatment, Inadequate filtration, Inadequate chemical feeding, No disinfection, Inadequate disinfection, Interruption of disinfection, Other (specify)

Investigator:
Title:
Agency:
Date:

Attachment 10- Form G5b
Source of Contamination and Treatment Failures that Allowed Survival of Pathogens or Toxic Substances (Footnote: Explain source of contamination and treatment failure and describe entry in more detail on back or on separate sheet.)

Complaint Number:
Name of Facility:
Location:
Person-in-Charge:
Phone:




Raw water intake [Checkboxes: Excessive pollution in relation to water treatment potential, Bypass connection by which raw water or partially treated water gets into distribution system, Nearby uncontrolled pollution, Other (specify)]

Fluoridation feed deficiencies (Checkbox)

Sedimentation deficiencies: [Checkboxes: No sedimentation before filtration, Turbidity not removed, Tank not cleaned, High population of microorganisms remain, Retention time, Other deficiencies (specify]
Sedimentation rate: Depth of water / transit time from inlet to outlet =

Record review:
Coagulant dose (Date/Value)
Residual coagulant (Date/Value)
pH (Date/Value)
Turbidity (Date/Value)

Other tests (specify)

Records show routine monitoring of measurements: (Checkboxes: Yes, No)

Turbidity performance criteria: [Checkboxes: Media loss, Media deterioration, Mud ball formation, Channeling, Surface cracking, Under drain failure, Cross connections, Chemical deficiencies (specify)]

Type filtration: [Checkboxes: Conventional (rapid), Direct (rapid), Pressure, Slow, Bag cartridge, Diatomaceous earth, Other (specify)]

Frequency of backwashing
Deficiencies of filtration
Recycling backwash water (Checkboxes: Yes, No)
Source of backwash water
Average filtered water turbidity:
Filter 1
Filter 2
Filter 3
Filter 4
Filter 5
Filter 6
Other filters (list on back)
Combined filter effluent
Clearwell effluent
Plant effluent

Nature of recent illnesses of staff (name of illness or major symptoms)
Name of employee

Other observations or measurement of treatment plant operations

Factors contributing to survival of pathogen or failure of inactivation of toxin during treatment and outbreak 

Checkboxes: Inadequate prefiltration treatment, Inadequate filtration, Inadequate chemical feeding, No disinfection, Inadequate disinfection, Interruption of disinfection, Other (specify)


Investigator:
Title:
Agency:
Date:
 
Attachment 11- Form G6
Source and Modes of Contamination during Distribution and at Point of Use (Footnote: Explain source/mode of contamination and describe entry in more detail on back or on separate sheet.)

Complaint Number:
Location:
Person-in-Charge/Owner:
Phone:

Type cross connections: (Checkboxes: Sewer lines, Waste lines, Fire water supply, Boilers, Carbonated water lines, Cooling water, Hydraulic operations, Other (specify))

Cross connection deficiencies: [Checkboxes: Deficiency of double check valve arrangement, Defective check valve(s), Defective other backflow prevention devices, Temporary attachment not detached Others (specify)]
Comments

Backsiphonage detected: [Checkboxes: Inlets without air gap, Inlet too close to fixture side/wall, Submerged inlet, Hose attachment in vessel, Defective vacuum breaker(s), Connections to sprinkler systems used to spray pesticides or toxic substances, Negative pressure, Other (specify]

Negative pressure occurred due to:
Checkbox: Water shut off due to repairs
Date(s):
Type repair(s)
Disinfection afterwards: (Checkboxes: Yes, No)
Checkbox: Repumping
Date(s)
Checkbox: Nearby fires
Date(s)
Checkbox: Intermittent service
Date(s)
Checkbox: Negative pressure on upper floors
Date(s)
Checkbox: Other (specify)
Date(s)

Sites sampled
1
2
3
4
5
6
7
8
9
10


Recent illness of persons in building
Type illness/major symptoms
Date(s)
Name of person(s)
Address
Phone

Chlorine residuals in distribution system
Free
Total
Location
Line pressure testing results
Results of other tests (specify test)

Previous month
Number of sites where disinfected residual was measured (a)
Number of sites where no disinfected residual measured, but HPC measured (b)
Number of sites where disinfected residual not detected and HPC not measured (c)
Number of sites where disinfected residual not detected, HPC criteria (e.g., > 500/ml) exceeded (d)
Number of sites where disinfected residual not measured, HPC criteria (e.g., > 500/ml) exceeded (e)

(Equation)
v = (c + d + e) / (a + b) x 100 =        %

Type of storage/transportation facility contaminated: [Checkboxes: Community storage tank, Cistern, Transportation tank, Household storage container, Other (specify)]

Factors contributing to distribution line contamination and outbreak (Footnote: Record on Form L)

Checkboxes: Cross connections and defective backflow prevention devices, Submerged inlet and backsiphonage, Contamination of storage tank, cistern, storage container, Improper or no disinfection of mains, plumbing or storage facility, transportation container after repairs or new construction, Line pressure loss, Other (specify)

Investigator:
Title:
Agency:
Date: