Form 0920-1424 Poliovirus Containment Sampling Points and Sanitation As

FORM APPROVED OMB NO. 0920-1424 EXP DATE: 12/31/2026

Poliovirus Containment Sampling Points and Sanitation Assessment Form for Wastewater (WW) Systems Supporting a Poliovirus- Designated Facility (PVDF) 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-designated facility (PVDF) containment breach. CDC will collect information on the wastewater system supporting the PEF to assess the environmental safeguard. The information collected in the form will be used by CDC to assess 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 (0920-1424).

Purpose of Assessment

• Describe and assess the PVDF WW system and the primary safeguards to reduce and control the release of poliovirus from the facility.

• Describe and assess WW system(s) from PVDF WW source to environmental release of treated effluent, including the closed sewage system.

• Describe and assess WW utilities that receive wastewater from the PVDF.

Poliovirus-Essential Facility

PEF name	Address	Phone	Contact person 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 PVDF 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 PVDF 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.

Closed Sewage Conveyance System

Can multiple WW utilities receive effluent from the PVDF (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 PVDF 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 PVDF 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 PVDF 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 PVDF.

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

PVDF 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

WW Treatment Facility

WW facility name	Address	Phone	Contact person and title	General description of community sewage treatment facility (e.g., conventional activated sludge treatment w/ anaerobic digestion)	Primacy agency and contact information

WW facility name	Year facility went into service	WW facility design flow (MGD)	Average WW daily flow (MGD)	Catchment population size	Emergency plan for facility exceeding capacity or not operational (provide detail)	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.).

WW treatment facility – operational information

WW facility name	Operational hours and days if facility does not operate 24/7/365	Dates facility has been nonoperational for longer durations (if applicable)	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?
	Indicate required
	vaccines for
	operators (e.g.,
	polio, Hep A,		Are operators
	DTaP);		certified for their
WW facility	Indicate recommended vaccines for operators (e.g.,	Are operators enrolled in an occupational	appropriate level and position as required by	Does operator training include the following? Mark all that apply (sources: training attendance logs held by primacy
name	Influenza)	health program?	primacy agency?	agency; OSHA compliance staff)
				General operation of the WW treatment facility General operation of sewer collection system Shut down and startup of WW treatment facility General maintenance General operation and maintenance of safety equipment Confined space entry Lock out/tag out procedures Excavation standards Pumps Electrical control panels

OSHA standards/competent person: notification process related to accidents and incidents Other:

WW facility name	Who performs maintenance (e.g., facility operators or private contractors)	Describe the program for validation and certification process (sanitary survey) (e.g., frequency, agency conducting survey, timing of survey)	What is included in the scope of the audit or sanitary survey? Check all that apply
			Treatment procedure and trend data Maintenance data tanks, equipment, and controls Test sample results and log of monitoring equipment calibration Safety plan up to date Emergency response plan up to date Closed sewage conveyance/piping system Physical condition of WW treatment facility Discharge monitoring results documentation As-builts documentation of overall system documented Other:

		Document historical	Is the treatment facility	Time required	Describe relevant environmental
WW	Describe key	issues with the WW	secured from	to cycle WW	factors in area receiving treated
facility	performance	treatment system	nonauthorized	through the	effluent from WW treatment
name	indicators*	sewage	personnel?	system	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.

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