0920 Poliovirus Containment Sampling Points and Sanitation As

FORM APPROVED
OMB NO. 0920-XXXX
EXP DATE: xx/xx/20xx

Poliovirus Containment Sampling Points and Sanitation Assessment
Form for Wastewater (WW) Systems Supporting a PoliovirusEssential Facility (PEF) in the United States

The United States (U.S.) must ensure environmental safeguards (i.e., closed sanitation systems and secondary

effluent waste treatment) and prepare for the unlikely but potential environmental release of poliovirus resulting
from a poliovirus-essential facility (PEF) containment breach. CDC will collect information on the wastewater
system supporting the PEF to assess the environmental safeguard in accordance with the World Health
Organization (WHO) Global Action Plan, 4th edition (GAPIV). The information collected in the form will be used by
CDC to assess the GAPIV environmental safeguard requirement, identify potential environmental sampling
locations as well as develop and test protocols as part of national preparedness and emergency response
planning.

Public reporting burden: CDC estimates the average public reporting burden for this collection of information as 1.5 hours per response, including
the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and
completing and reviewing the collection information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Review Office;
1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Poliovirus Containment Sampling Points and Sanitation Assessment Form for WW Systems Supporting a PEF in the United States—page 1

Purpose of Assessment
•
•
•

Describe and assess the PEF WW system and the primary safeguards to reduce and control the release of poliovirus from the facility.
Describe and assess WW system(s) from PEF WW source to environmental release of treated effluent, including the closed sewage
system.
Describe and assess WW utilities that receive wastewater from the PEF.

Poliovirus-Essential Facility
PEF
name

Contact person
Address Phone and title

Brief general description of WW
treatment safeguards at facility

WW produced
annually (G/Y)

Average WW daily
flow (G/D)

Describe the closed piped sewer system within the PEF up to its entry into the closed sewage conveyance system. Maps or drawings
preferred.
•
•

Description could include GIS mapping, imagery, or engineering drawings of the sewerage network within the PEF to where it enters
the closed sewage conveyance system.
Mapping should display gravity sewage flows between fixtures, sampling points (if applicable), and any other pertinent information
before the sewage exits the facility and enters the closed sewage conveyance system.

Poliovirus Containment Sampling Points and Sanitation Assessment Form for WW Systems Supporting a PEF in the United States—page 2

Closed Sewage Conveyance System
Can multiple WW utilities receive effluent from the PEF (e.g., via a diversion manhole/control structure)? Describe the wastewater
conveyance system between PEF and wastewater utility (e.g., length and other attributes).

PEF
name

Is WW
treated
onsite?

Associated
WW
treatment
facility(ies)

Type of conveyance system
and description (number of
connections on conveyance
system, frequency of
maintenance visits)

Length of
conveyance system
between PEF and
WW treatment
facility

Number of
access or
sampling
point(s)

Description of sewage lift
stations (number, locations,
type, and general
information such as pumps,
control panel, security)

Describe the closed piped sewer system from the PEF to the associated WW treatment facility(ies). Maps or drawings preferred.
•
•

Description could include GIS mapping, imagery, or engineering drawings of the sewerage network from PEF to WW treatment
facility.
Mapping should display gravity sewage flows between manholes, lift stations, force mains, sampling points (if applicable), and any
diversion/control structures that can divert flow to secondary WW treatment facility. If multiple WW treatment facilities serve the
community, highlight the population area served by the WW treatment facility that also serve the PEF.

Document historical issues with leaks or breaks, construction, and maintenance issues associated with the closed sewage conveyance
system.

PEF
name

Associated WW
treatment
facility(ies)

Frequency and number
of planned maintenance
visits

Document historical issues with the conveyance system sewage
(backups, leaks, breaks, new construction or renovation,
maintenance [jetting and cleaning], and sewer video or scoping
recording logs

Notes

Poliovirus Containment Sampling Points and Sanitation Assessment Form for WW Systems Supporting a PEF in the United States—page 3

WW Treatment Facility
WW
facility
name

WW
facility
name

Contact
person and
Address Phone title

Year facility
went into
service

WW facility
design flow
(MGD)

General description of community sewage treatment facility
(e.g., conventional activated sludge treatment w/ anaerobic
digestion)

Average WW
daily flow
(MGD)

Catchment
population size

Emergency plan for facility
exceeding capacity or not
operational (provide detail)

Primacy agency and
contact information

Dates and
descriptions of
renovations

Describe the sewage flow within the WW treatment facility. Maps or drawings preferred.
•
•

Description could include GIS mapping, imagery, or engineering drawings of the sewerage network from the outlet of the closed
sewage conveyance system to within the WW treatment facility.
Mapping should display gravity and pressurized sewage flows between mechanical or natural sewage treatment components,
sampling points (if applicable), and any other pertinent information before the treated sewage exits the WW facility and enters the
natural water body (stream, river, lake, etc.).

Poliovirus Containment Sampling Points and Sanitation Assessment Form for WW Systems Supporting a PEF in the United States—page 4
WW treatment facility – operational information
Dates facility has been
Operational hours nonoperational for
WW
and days if facility longer durations (if
facility
does not operate
applicable)
name
24/7/365

Number of days facility
has been
nonoperational for
longer durations (if
applicable)

Public or
private
WW
system?

Operating entity
(government, local
government,
contractor)

Describe
sewage
treatment
steps for
facility

WW treatment facility – operator information
Are operators
vaccinated for
poliovirus?

WW
facility
name

Indicate required
vaccines for
operators (e.g.,
polio, Hep A,
DTaP);
Indicate
recommended
vaccines for
operators (e.g.,
Influenza)

Are operators
enrolled in an
occupational
health program?

Are operators
certified for their
appropriate level
and position as
required by
primacy agency?

Does operator training include the following? Mark all that
apply (sources: training attendance logs held by primacy
agency; OSHA compliance staff)
1. General operation of the WW treatment facility
2. General operation of sewer collection system
3. Shut down and startup of WW treatment facility
4. General maintenance
5. General operation and maintenance of safety equipment
6. Confined space entry
7. Lock out/tag out procedures
8. Excavation standards
9. Pumps
10. Electrical control panels

Poliovirus Containment Sampling Points and Sanitation Assessment Form for WW Systems Supporting a PEF in the United States—page 5
11. OSHA standards/competent person: notification process
related to accidents and incidents
12. Other: ________________________________________

WW
facility
name

Who performs
maintenance (e.g., facility
operators or private
contractors)

WW
facility
name

Describe key
performance
indicators*

Describe the program for validation and
certification process (sanitary survey)
(e.g., frequency, agency conducting
survey, timing of survey)

Document historical
issues with the WW
treatment system
sewage

Is the treatment facility
secured from
nonauthorized
personnel?

What is included in the scope of the audit or
sanitary survey? Check all that apply
1. Treatment procedure and trend data
2. Maintenance data tanks, equipment, and
controls
3. Test sample results and log of monitoring
equipment calibration
4. Safety plan up to date
5. Emergency response plan up to date
6. Closed sewage conveyance/piping system
7. Physical condition of WW treatment facility
8. Discharge monitoring results
documentation
9. As-builts documentation of overall system
documented
10. Other: ____________________________

Time required
to cycle WW
through the
system

Describe relevant environmental
factors in area receiving treated
effluent from WW treatment
system (e.g., river, lakes, streams)

*Examples include biological burden on different treatment steps, during rainy days, during drought, during different seasons, when sewage
composition changes drastically, peak performance WW processing times.