Disinfection / chlorination certificate
A certificate and record of any system disinfection: chemical (chlorination) or thermal: capturing the method, concentration, contact time and post-disinfection verification.
This PDF is not tagged for assistive technology. Use the accessible HTML worksheet below to complete it online, or use the structured CSV.
Fill in online
Complete this worksheet online
- Complete only from an approved method statement and contemporaneous measurements, including the product concentration basis, pH and residual verification.
- This record does not prove that treatment was effective or that the system is safe; competent verification and follow-up may be required.
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Enter the date.
Enter the system/area treated, or leave it blank if not known.
Enter the method, or leave it blank if not known.
Enter the disinfectant & conc., or leave it blank if not known.
Enter the contact time, or leave it blank if not known.
Enter the post-flush result, or leave it blank if not known.
Enter the contractor, or leave it blank if not known.
Enter the cert ref, or leave it blank if not known.
| Date | System/area treated | Method | Disinfectant & conc. | Contact time | Post-flush result | Contractor | Cert ref |
|---|---|---|---|---|---|---|---|
| 2026-06-16 | CWST & distribution | Chlorination | Chlorine, target per procedure | Per procedure | Residual neutralised; OK | Competent contractor | DIS-2026-031 |
| 2026-06-16 | Hot water service | Thermal | N/A (heat) | Per procedure | Outlets reached target temp | Competent contractor | DIS-2026-032 |
Sample rows are illustrative. Download the PDF for a clean print-ready form, or the CSV to fill in digitally.
How to use it
- Complete a certificate whenever a system is disinfected: after remedial works, a positive result, commissioning, or following a shutdown.
- Record the method, the disinfectant and target concentration (or temperature for thermal), and the contact time achieved, following a written procedure.
- Record the verification step (e.g. neutralisation and confirmation of normal residual, or confirmation of target temperatures) before the system is returned to use.
- Keep the signed certificate with your logbook; follow the disinfectant concentrations and contact times in your procedure and BS/HSG guidance rather than assumed figures.
Background: Certificate of disinfection: what it is, what it should show and when you need one
"Disinfection / chlorination certificate (free template)." Legionella.io. https://legionella.io/templates/disinfection-certificate-record/
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