Rapid assessment of drinking-water quality in the - WHO/UNICEF ...

Annex 9
Governorate 2
Cluster No.
Sample Site No. 3
Record sheet for a RADWQ sanitary
inspection
WSS No. 1
JO __ __ __ __ __ __
1. WSS No. = unique code identifying a sample site (Water Supply Scheme Number;)
2. Broad Area: Amman = 11, Albalqa = 12, Alzarqa = 13, Madaba = 14, Irbid = 21, Almafraq = 22, Jarash = 23, Ajloun = 24, Alkarak =
31, Altafiela = 32, Ma’an = 33, Aqaba = 34;
3. Sample Site No. = 1–24 (NB: Sample Site No. where household samples are collected = 90, household samples = 91–95).
Name of Community (Town/Village):
WSS Type: Chlorinated supply Y
ٱ N ٱ (a) - Piped Water Treatment Process
ٱ - Piped Water Distribution System
ٱ - Household Piped Water
ٱ Name of Inspector/Analyst:
Date of visit (inspection date):
Time:
1. Sanitary Risk Inspection (CHOOSE APPROPRIATE FORM)
P IPED W ATER T REATMENT P ROCESS
Risk
1. Are cracks evident in the pre-filters Y
ٱ N ٱ 2. Are there leaks in the mixing tank Y
ٱ N ٱ 3. Is the mixing tank in an insanitary condition Y
ٱ N ٱ 4. Are hydraulic surges evident at the intake Y
ٱ N ٱ 5. Is any sedimentation tank in an insanitary condition Y
ٱ N ٱ 6. Is the air and water supply distribution in any sand bed uneven Y
ٱ N ٱ 7. Are there mud balls or cracks in any of the filters, or is the filter performance not good Y
ٱ N ٱ 8. Are cross-connections evident between backwashed and treated water Y
ٱ N ٱ 9. Is there evidence that insufficient doses of coagulant (e.g. alum) are being used Y
ٱ N ٱ 10. Are free residual chlorine concentrations (minimum 0.2 mg/l) not being achieved, or is the
retention tank missing
Y
ٱ N ٱ Total Score of Risks: /10
P IPED W ATER D ISTRIBUTION S YSTEM
Risk
1. Do any taps or pipes leak at the sample site Y
ٱ N ٱ 2. Does water collect around the sample site Y
ٱ N ٱ 3. Is the area around the tap insanitary Y
ٱ N ٱ 4. Is there a sewer or latrine within 30 m of any tap Y
ٱ N ٱ 5. Has there been discontinuity in the water service in the last 10 days Y
ٱ N ٱ 6. Is the supply main exposed in the sampling area Y
ٱ N ٱ 7. Do users report any pipe breaks within the last week Y
ٱ N ٱ 8. Is the supply tank cracked or leaking Y
ٱ N ٱ 9. Are the vents and covers on the tank damaged or open Y
ٱ N ٱ 10. Is the inspection cover or concrete around the cover damaged or corroded Y
ٱ N ٱ 55