Form DOH-4472 "Swimming Pool Safety Plan" - New York

What Is Form DOH-4472?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2011;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DOH-4472 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-4472 "Swimming Pool Safety Plan" - New York

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NEW YORK STATE DEPARTMENT OF HEALTH
Swimming Pool Safety Plan
Bureau of Community Environmental Health and Food Protection
Name of Facility ____________________________________________________________________________________________
Site Address ________________________________________________________________________________________________
_________________________________________________________________________________________________________
Telephone _________________________________________________________________________________________________
Prepared By ________________________________________________________________________________________________
Title ______________________________________________________________________________________________________
Signature ________________________________________________________ Date ____________________________
New York State Sanitary Code 6-1 requires that swimming pool operators develop, update and implement a written safety plan.
This plan must be submitted to your local health department for their review and approval. The plan must include procedures
for daily bather supervision, injury prevention, reacting to emergencies, injuries and other incidents, providing first aid and
summoning help.
Please review and complete this document. Include any attachments (i.e. photos), as necessary. Once completed, it will serve
as your facility’s comprehensive written safety plan, which will meet the requirements of the State Sanitary Code (SSC). This
plan must meet the specific conditions of your facility and operations, as well as serve as a training and reference document
for you and your staff. Local rescue, police and fire personnel should be consulted when developing your pool safety plan.
Additional information may be obtained at http://www.health.ny.gov/
Please send a copy to:
And, please retain a copy of this document for your use.
FOR LHD USE ONLY
Approved
Yes
No
Reviewer _____________________________________________________
Title _________________________________________________________ Date __________________________
DOH-4472 (2/11) Page 1 of 28
NEW YORK STATE DEPARTMENT OF HEALTH
Swimming Pool Safety Plan
Bureau of Community Environmental Health and Food Protection
Name of Facility ____________________________________________________________________________________________
Site Address ________________________________________________________________________________________________
_________________________________________________________________________________________________________
Telephone _________________________________________________________________________________________________
Prepared By ________________________________________________________________________________________________
Title ______________________________________________________________________________________________________
Signature ________________________________________________________ Date ____________________________
New York State Sanitary Code 6-1 requires that swimming pool operators develop, update and implement a written safety plan.
This plan must be submitted to your local health department for their review and approval. The plan must include procedures
for daily bather supervision, injury prevention, reacting to emergencies, injuries and other incidents, providing first aid and
summoning help.
Please review and complete this document. Include any attachments (i.e. photos), as necessary. Once completed, it will serve
as your facility’s comprehensive written safety plan, which will meet the requirements of the State Sanitary Code (SSC). This
plan must meet the specific conditions of your facility and operations, as well as serve as a training and reference document
for you and your staff. Local rescue, police and fire personnel should be consulted when developing your pool safety plan.
Additional information may be obtained at http://www.health.ny.gov/
Please send a copy to:
And, please retain a copy of this document for your use.
FOR LHD USE ONLY
Approved
Yes
No
Reviewer _____________________________________________________
Title _________________________________________________________ Date __________________________
DOH-4472 (2/11) Page 1 of 28
SECTIONS
Pool Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Bather Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Homeowner Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Supervision Level IIa or IIb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Supervision Level III or IV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Certifications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Injury Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Waterfront Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Lighting and Electrical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Rules and Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Diving Areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Starting Block Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Pool Slides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Environmental Conditions and Weather . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Illness Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Fecal, Vomit and Blood Contamination Incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Chemical Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Spas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Search Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Sketch/Diagram of Pool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
DOH-4472 (2/11) Page 2 of 28
DOH-4472 (2/11) Page 3 of 28
BATHER SUPERVISION
• The effective supervision of all bathers is essential to safety. Inadequate supervision has been determined to be
a contributing cause in over half of all drownings at regulated bathing facilities in New York State.
• A system is to be established that allows for continuous supervision and adequate visual surveillance of the bathers.
This system will vary depending on the level of supervision required at each facility type.
• When a swimming pool, spa pool or wading pool is part of a temporary residence or campground as defined in SSC
Subparts 7-1 and 7-3, the operator must provide either Supervision Level IIa, IIb, lll, or lV aquatic supervision, as defined
in SSC Subpart 6-1.
• For other pools, not associated with a temporary residence or campground, the supervision level required at each is
dependent on water depth, size of the pool, diving boards, deck slides, and flotation devices used.
• Additional supervisory staff may be required by the permit-issuing official (PIO). Factors, including but not limited to,
pool shape, diving board use, patron decorum, patron alcohol consumption, and, bathing facilities used primarily for the
developmentally disabled may be the basis for increased coverage.
• Homeowner swimming pools are exempt from the supervision requirements, except:
– If a homeowner swimming pool is used by people other than the owner/residents, their friends, renters or guests,
then the operator must comply with applicable regulations during those periods of use. (Please refer to SSC Sections
6-1.2(o) and 6-1.23(a)(2).)
Is your pool(s) operated by a Homeowner Association?
Yes
No
If “yes” to question above, please continue with questions 3-5 and 28-70.
Supervision Level IIa or IIb – Pool (Only) or Pool and Beach Lifeguard
• Unless associated with a temporary residence or campground, Supervision Level IIa or IIb must be provided at all
whitewater slides, wave pools or aquatic amusements and when any of the following are present: water depth is five feet
or greater; diving boards; flotation devices other than U.S. Coast Guard Type I–III; pool deck slides; surface area of the pool
exceeds 2,000 square feet.
Do you provide Supervision Level IIa or IIb at your facility?
Yes
No
If “yes” to question above, please continue with questions 6-17 and 28-70.
DOH-4472 (2/11) Page 4 of 28
Supervision Level III or IV
• Are supervisory staff, provided by the facility, who possess certain skills and requirements per Section 6-1.31.
• May be selected when the bathing facility is part of a temporary residence or campground.
• If part of a temporary residence or campground, when Supervision Level III or IV is selected, on-premise CPR is not required.
• If a temporary residence or campground operator allows persons other than registered overnight patrons and their
guests to use the pool , then the operator must provide a leveI of supervision during that period of use which is consistent
with the pool characteristics. (Please refer to Subpart 6-1.23(a)(2).)
– Pools with surface area greater than 2000 square feet, water depth 5 feet or more, diving boards, flotation devices (other
than U.S. Coast Guard Type I–III Label), or pool deck slides must provide Supervision Level II, a lifeguard.
– When a pool otherwise qualifies for Supervision Level III or IV, on-premise CPR certified staff are required.
Supervision Level III
• Supervision Level III is required at all spas and wading pools, if not associated with a temporary residence or campground.
Supervision Level III Staff for Instructional Activities
• When instructional activities occur and the lifeguard is also providing the instruction, additional staff must be provided who
have at least the Supervision Level III required certification.
– This Level III staff is not expected to perform as a lifeguard, i.e. water rescues, etc., but to provide additional surveillance
and possess victim recognition skills to assist the lifeguard during these instructional activities.
Supervision Level IV
• Supervision Level IV may be selected if the water depth within the designated bathing area is less than five feet and the
surface area of the pool is less than or equal to 2000 square feet.
• At Supervision Level IV, the aquatic staff shall be on premises at all times the pool or spa is in use with periodic visual
checks of the pool or spa conducted and logged.
Do you provide Supervision Level III at your facility?
Yes
No
If “yes” to question above, please continue with questions 18-21 and 28-70.
Do you provide Supervision Level IV at your facility?
Yes
No
If “yes” to question above, please continue with questions 18-70.
DOH-4472 (2/11) Page 5 of 28