Fluoridation Self- Assessment Questionnaire						
Quality Assurance Sub-Committee of the Irish Expert Body on Fluorides and Health

Name(s) of Water Treatment Plant: ______________________________________________	Unique Identifier Number:_________________

Name of Local Authority:  ___________________________________________			Date: ______________

Name of the Assessor: ___________________________________					Signature: _____________________________ 

Position of the Assessor: _____________________________
Item	Ref Code of Practice	Y/N
	Hazard	Probability	Risk	Reason for Non-Compliance	Planned Corrective Action	Completion Date	
COMPLIANCE WITH STANDARDS									
Is there an up to date documented management and control system in place?
	Section 4								
Is there an up to date Material Safety Data Sheet and Certificate of Analysis readily available for HFSA  
	Section 5.1								
Is there an up to date Material Safety Data Sheet and Certificate of Analysis readily available for testing reagents e.g. SPADNS 
	Section 5.1								

FLUORIDATION PLANT OPERATION									

Is the transfer of HFSA taking place in an area where there is a direct pathway to either surface water or groundwater 	Section 6.2								
Is the bulk storage tank located within a bunded area (contains spills and prevents water pollution) capable of accommodating at least 110% of tank capacity?

	Section 6.2.3								
Is the fill point located within a bunded area appropriately sized for the fill point?
	Section 6.2.1								
Is there a written procedure for response in the event of HFSA not meeting the specification?

	Table 1								

Do all tanks have a fill pipe with non-return valve?
	
Section 6.2.1			
					
Is there a unique coupling valve arrangement to prevent inadvertent coupling to an inlet pipe for other chemical agents?	Section 6.2.2								
Are tanks and pipe-work for HFSA correctly and clearly labelled or distinguishable (e.g. colour coded) from other process pipe-work or tanks?	Section 6.5.1								
Is pipe-work for HFSA enclosed in an acid resistant conduit? 
	Section 6.5.1								
Does bulk storage tank have a clearly readable contents level indicator? 
	Section 6.2.2								
 Is the contents level indicator checked daily?	Section 6.2.2								
Is bund integrity testing carried out every 5 years?
	Section 6.2.3								
Are there records of the last two bund integrity tests available?	Section 6.2.3								
Are the contents of the bund tested for fluoride prior to release to surface water?  	Section 6.2.3								
Are the bulk storage tanks constructed from suitable acid resistant material?	Section 6.2.2								
Is the bulk tank connected to a day tank?

	Section 6.3.2								
How many days capacity are stored in the day tank?	Section 6.3.3								
Are there fail-safe filling arrangements for the day tank?	Section 6.3.2
Section 6.4.2								
Is there adequate lighting provided for inspection of the day tank?

	Section 6.3.5								
Are bulk tanks and day tanks that are sited indoors vented to outdoors?	Section 6.3.4
Section  6.2.5								
Are day tanks vented to outdoors?	Section 6.3.4								
Is there an exhaust that is activated when the door is opened into the day tank storage area	Section 6.3.4								
Are integrity checks carried out on storage and day tanks?	 N/A								

Is the fluoride dosing pump located in the bund?
	
Section 6.4.1								
Is there a level indicator and contents gauge fitted to the bulk storage tank (including electronic sensors)?	Section 6.2.2								
Are there high and low level probes/alarms?	Section 6.2.2								
Is there a means of determining the amount of acid used per day /period e.g. weighing scales?	Section 5.4								
Is the pump operating within the manufacturers operating range? 	Section 6.4.3								
Is the pump at the correct height?

	Section 6.4.1								
Is the dosing pump interlocked for safety?

	Section 6.4.2								
Is there backflow protection?	Section 6.4.4								
Is there a duty/standby dosing pump in case of pump malfunction?
	Section 6.4.5								

CALIBRATION									
Is there a preventative maintenance programme in place for pumps, fluoride testing equipment and weighing scales?	Section 6.4.6								
Is there a documented calibration programme for pumps in place?  
	Section 6.4.6								
Is there a documented servicing and calibration programme for fluoride testing equipment?	Section 6.4.6								
Is there a documented servicing and calibration programme for weighing scales?	Section 6.4.6								
Are the calibration records retained?	N/A								
In the event of breakdown of equipment, is the equipment re-calibrated?	N/A								
SAMPLING AND MONITORING 									
Is there a fluoride monitoring programme in place in the water treatment plant?   	Section 6.6.2								
Is the daily checklist carried out?	Appendix 4								
Is there daily online or suitable colorimetric testing being carried out on a daily basis in the water treatment plant for fluoride monitoring? 	Section 6.6.2								
Is the SPADNS technique an open or closed system?	N/A								
Is the volumetric calculation done?	Section 6.6.2.2								
Where is this calculation recorded?	Section 6.6.2.2								
Is the volumetric result cross checked against the colorimetric results?	Section 6.6.2.2								
Are natural background fluoride levels (raw water) being monitored at least twice a year?	Section 6.6.2.3								
RECORDS									
Are copies of the daily fluoride test results forwarded to the relevant local authority engineer/chemist on a monthly basis?	Section 6.6.3.1								
 Are the results recorded in a standard format?	N/A								
How are these results forwarded to the relevant personnel?	Section 6.6.3.1								
How are these results stored?	Section 6.6.3.1								
How long are these results stored for?	N/A								
INVESTIGATION OF NON-COMPLIANCES									
Is there a standardised procedure following a non-conforming test result?
	Table 2								
ENVIRONMENTAL WASTE									
What is the procedure to use in the event of a spillage of HFSA	Appendix 3								
How is waste or used SPADNS disposed of?	Appendix 3								
Is there a procedure in place for commissioning/decommissioning/
re-commissioning water fluoridation plant, or redundant equipment and material?	Section 7								

TRAINING									
Have all fluoridation plant personnel received training specific to water fluoridation before commencing duties? 
	Section 9								
Is it formal training with (WSNTG)	Section 9.1								
Is refresher training completed by relevant personnel every 5 years?	Section 9								
Have all fluoridation plant personnel been trained in the use of PPE, emergency procedures, flushing, showering and eyewash facilities, handling procedures and any other relevant Health and Safety training before commencing duties?	Section 9.3								

ACCIDENT/EMERGENCY									
Are emergency shower and emergency eye-wash facilities located close to both the bulk storage and day tanks?	Section 10.3.3								
Is there a first-aid kit on site
	Section 10.3.3
Appendix 1								
Are all dangerous occurrences/accidents related to the fluoridation process reported and investigated?
	Section 10.3.4								
Is there a list of emergency contacts available?
	Section 10.3.5								
Is there a written emergency procedure?
	Appendix 3
Appendix 2								
Are there spill kits e.g. lime, earth or sand for any spillages?
	Appendix 3								
SITE SECURITY									
Is there a formal written security procedure?
	Section 6.1								
Is the site secure and is unauthorized access prevented?	Section 6.1.1								
Is lighting adequate in all areas?

	Section 6.2.4
Section 6.3.5								
Are all parts of this treatment area in a good state of repair?
	N/A								
Is external pipe-work  and delivery point adequately protected from accidental damage or vandalism?	Section 6.2.2