Environmental Health Services
225 Camino del Remedio, Santa Barbara, CA 93110 (805) 681-4900 FAX (805) 681-4901
2125 S. Centerpointe Pkwy. #333, Santa Maria, CA 93455-1340 (805) 346-8460 FAX (805) 346-8485
Incident Response Log
Affected pool
Person conducting contamination response
Supervisor on duty
Date of incident (mm/dd/yyyy)
Time of incident
Length of time between the occurrence and detection of
incident
Number of pool users in pool at the time of the incident
Type of contamination in
water:
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□
□
□
□
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Fecal - formed
Fecal - diarrhea
Vomit
Blood
Drowning
Near drowning
Other, describe:
Describe the known facts, circumstances and cause of incident:
Cyanuric acid concentration
Prior to Disinfection
After Completion of
Disinfection Process
At Reopening
Free residual chlorine concentration
pH
Temperature
Date that pool was reopened (mm/dd/yyyy)
Time that pool was reopened
Time between detection and resolution of incident
Describe remediation procedure(s) used in responding to the contamination incident:
If two or more lifeguards or pool users at a public pool report within 5 days of each other to the pool operator that they have
had diarrhea, the pool operator shall report this to Environmental Health Services.
EHS 36-6 (Rev. 07/02/15)
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