Hospital Tap Water Scheme Request Report Form

Food and Environmental Proficiency Testing Unit
Laboratory identification no. (check): / Please enter your lab number
Dispatch date: / 12 March 2018
Final date for return of results: / 06 April 2018
Contact details:
The Organisers - FEPTU
Public Health England
61 Colindale Avenue,
London, NW9 5EQ, UK.
Fax: +44 (0) 20 8200 8264
Tel: +44 (0) 20 8327 7119
e-mail: /
0006
www.gov.uk/government/collections/external-quality-assessment-eqa-and-proficiency-testing-pt-for-food-water-and-environmental-microbiology#hospital-tap-water-scheme
Hospital Tap Water Scheme Request/Report Form
Distribution No: HTW12 / Sample numbers: HTW12A and HTW12B
Download the sample instruction sheet. A video on sample processing is located further down the webpage: / www.gov.uk/government/publications/hospital-tap-water-scheme-sample-instruction-sheets
Download the safety data sheet: / www.gov.uk/government/publications/safety-data-sheet-for-lenticules
If you cannot examine any of these samples return your results as ‘Not examined’
Request: / Please examine the sample for P. aeruginosa, if present determine the levels per 100mL using your routine method.

Results:

Sample Number / Enumeration / Not examined / Result / Conclusion or Comment/s
(Please tick)
HTW12A / P. aeruginosa per 100mL / o / Satisfactory / o
Comply with local policy / o
No further action required / o
Unsatisfactory / o
Retest (pre-/post-flush) / o
Risk-assess and retest (pre-/post-flush) as stated in HTM 04-01 part B / o
No comments/interpretation by laboratory provided / o
Other, please state / o
Sample Number / Enumeration / Not examined / Result / Conclusion or Comment/s
(Please tick)
HTW12B / P. aeruginosa per 100mL / o / Satisfactory / o
Comply with local policy / o
No further action required / o
Unsatisfactory / o
Retest (pre-/post-flush) / o
Risk-assess and retest (pre-/post-flush) as stated in HTM 04-01 part B / o
No comments/interpretation by laboratory provided / o
Other, please state / o
Please indicate the method used / o / MPN (most probable numbers)
o / MF (Membrane filtration)
o / Other
Please indicate the media used / o / PCFC/CFC (Pseudomonas, cetrimide, fucidin and cephaloridine)
o / PCN (Pseudomonas cetrimide sodium nalidixate agar)
o / Pseudalert®
o / Other
Standard/Guideline followed / o / ISO 16266
o / HTM 04-01 part B
o / Local guidelines or legislation
o / EN 12780
o / Microbiology of Drinking Water (2010)
Additional comments
Authorised by: / Date reported:

Page 2 of 2