Template

Backflow Test Report Template

by daniel van oosten, from the Community

This Backflow Test Report template helps plumbers, licensed testers, and utilities record and certify backflow prevention assembly tests. Capture title and site details, facility manager and assembly location, and gauge information including make, model, serial number, and calibration date. Select assembly type RP, DC, PVB, or SVB and enter serial numbers. Document valve and relief valve checks, differential readings, backpressure tests, shut off valve status, pass or fail results, and remarks. Finish with tester certification, certificate number, and date and time to support compliance and water safety programs.

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Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

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This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
Backflow Test Report
This Backflow Test Report template helps technicians and water utility teams record all details from backflow prevention assembly tests. Capture assembly type and serial number, gauge make, model, and calibration date, then document RP, DC, PVB, and SVB test results including check valve leakage, relief valve operation, and pressure readings in PSI/PSID. Mark pass or fail outcomes, add remarks, and complete tester certification with name, certification number, and date or time. Use this form to standardize inspections, maintain regulatory compliance, and ensure safe potable water systems across facilities and municipalities.
by Botha CG, from the Community
Downloads: 10+
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Template
MB Backflow Device Report Template
Use this MB Backflow Device Report template to document backflow prevention device testing and compliance. Record property and site details, device make, model, serial number, size and type, and the date of test. Capture authorized tester credentials, licence number, and contact information, along with results and notes. Ideal for licensed plumbers and facilities teams to standardize reporting, maintain records for audits, and meet local codes and water authority requirements.
by Shane Stevanovich, from the Community
Downloads: 10+
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Template
Backflow Inspection Checklist
Use this backflow inspection template to document backflow prevention devices across your site. Record asset numbers, make and model, device type and location, capture photos, note defects, estimate repair budgets, and document required works. Support plumbing compliance, water safety, and facility maintenance with clear reports and sign off.
by Cardinia Campeyn Group, from the Community
Downloads: 10+
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Template
Backflow Prevention Device Inspection and Maintenance
This backflow prevention device inspection and maintenance report template helps facilities and maintenance teams record comprehensive details during testing. Capture property and device information, meter and serial numbers, device type and manufacturer, and add photos of the unit and serial plate. Log test results for check valves, relief valve opening pressures (RPZD), bypass assemblies, and downstream isolation valves, including differential pressures in kPa. Note required repairs or part replacements, and mark pass or fail outcomes. Record test kit identification and calibration dates, technician or contractor details, licencing, certifications, tester name, signature, test date, and comments. Designed to support compliance with AS2845 and local regulations across water systems such as domestic, fire services, irrigation, medical, and mechanical plant connections.
by Josip Prahovic, from the Community
Downloads: 10+
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Backflow Test Report Template

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Backflow Test Report

MB Backflow Device Report Template

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Backflow Test Report

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