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    This document is an inspection report for a shower/decontamination point. It lists 11 criteria that are checked during the inspection, including ensuring the water source is safe, the shower unit and facilities are clean and properly maintained, safety equipment and supplies are sufficient, and water samples are checked. The report documents the results of the inspection and provides space for comments and recommendations to address any issues found.

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    DA FORM 5458

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    This document is an inspection report for a shower/decontamination point. It lists 11 criteria that are checked during the inspection, including ensuring the water source is safe, the shower unit and facilities are clean and properly maintained, safety equipment and supplies are sufficient, and water samples are checked. The report documents the results of the inspection and provides space for comments and recommendations to address any issues found.

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    23 views2 pages

    Da Form 5458

    Uploaded by

    Time of
    This document is an inspection report for a shower/decontamination point. It lists 11 criteria that are checked during the inspection, including ensuring the water source is safe, the shower unit and facilities are clean and properly maintained, safety equipment and supplies are sufficient, and water samples are checked. The report documents the results of the inspection and provides space for comments and recommendations to address any issues found.

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    of 2

    SHOWER/DECONTAMINATION POINT INSPECTION REPORT DATE

    For use of this form see TB MED 577; the proponent of this form is the Office of The Surgeon General.
    TO FROM

    INSPECTION RATING SHOWER POINT NO MAP COORDINATE LOCATION

    OPERATING UNIT TEAM CHIEF UNIT REPRESENTATIVE

    INSPECTING UNIT DATE/TIME GROUP INSPECTED BY

    INSPECTION CHECKLIST CRITERIA


    YES NO
    1. SITE CONDITIONS a. Adequate Drainage
    b. Rodent/Insect Breeding Areas
    Controlled
    c. Separate Latrines Provided
    d. Latrines Adequate ( Men/ Women)
    e. Handwashing Devices Present
    f. Garbage Control Practiced

    2. WATER SOURCE a. Nonpotable Water Chlorinated


    b. Chemical Agents Present
    c. Radioactivity Present
    d. Procured From:
    3. WASTEWATER CONTROL a. Drainage Ditches Adequate
    b. Effluent Discharge > 25 Yds
    Downstream
    c. Decontamination Waste Sump Present
    d. Proper Sump Closeout and Marking

    4. INTAKE LINE a. Intake Strainer Attached


    b. > 4 In From Surface or Bottom

    5. SHOWER UNIT a. Showers/Floor Clean


    b. Air Circulation Provided
    c. Nonpotable Water Sign Posted

    6. GENERATOR a. Located > 50 Ft From Showers


    b. Grounding Present
    c. Fire Extinguisher Present
    d. Hearing Protection Used
    e. Sufficient Ventilation
    7. OPERATOR MONITORING a. Chlorine Residuals Checked
    b. Chemical Agents Present
    c. Radioactivity Present
    d. Shower Water Temperature Checked

    8. WATER STORAGE a. Tanks Level


    b. Safety Bottom Apron Used
    c. Open Top Tanks Covered
    d. Tanks Clean and Sanitary
    e. Capacity Sufficient for Issue

    DA FORM 5458, NOV 2005 APD LC v1.01ES


    INSPECTION CHECKLIST CRITERIA
    YES NO
    9. RECORDS a. Bath and Clothing Exchange
    Report Used
    b. Blank Forms Sufficient

    10. SUPPLY STORAGE a. Fuel and Chemicals Sufficient


    b. Chemical Containers Labeled/Capped/
    Dry
    c. Activated Carbon and Calcium
    Hypochlorite Stored Separately
    11. SHOWER WATER SAMPLES a. Chlorine Residuals Checked
    b. Chemical Agents Present
    c. Radioactivity Present
    d. Shower Water Temperature Checked
    COMMENTS AND RECOMMENDATIONS:

    PRINTED/TYPED NAME AND GRADE OF PVNTMED INSPECTOR: SIGNATURE:

    DA FORM 5458, NOV 2005 APD LC v1.01ES

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