Guidelines for Pool and Spa Operators - Arkansas Department of

Record of Pool Contamination Incident
Date of incident: _________________ Time of incident: __________________
Name of individual responsible for incident: ________________________________________________
Home Address: _______________________________________
City, AR, Zip: ________________________________________
Male ____ Female ____
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
___________________________________________
Name of person in charge at the time of the incident
Is person in charge CPO certified?
___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
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