The Five Elements

Program Foundation

The Five Elements of a Cross Connection Control Program.

R309-105-12 requires every public drinking water system to establish and actively enforce a Cross Connection Control Program. These five elements help systems prevent contamination from entering the water distribution system.

Element 1

Local Authority Statement.

Ordinance Template

Sample ordinance language for establishing local authority.

Policy Template

Sample policy language for Cross Connection Control Program authority.

Element 2

Public Awareness.

Public Awareness Tracking Form

Track public education and awareness activities.

WATTS Backflow Packet

Public education packet for backflow prevention awareness.

Thermal Expansion Letter

Sample letter for educating customers about thermal expansion.

Protect Your Drinking Water Flyer

Public flyer explaining Cross Connection Control protection.

Welcome to Backflow City

Educational video about backflow and cross connections.

Chemical Dispensers Packet

Information packet covering chemical dispensers and cross connections.

Landscaping Backflow Postcard

Simple public education postcard for landscaping-related backflow risks.

Landscape Options Postcard

Public education postcard outlining landscaping backflow options.

Hose Bibb Vacuum Breaker Demo

Educational video demonstrating hose bibb vacuum breaker protection.

Element 3

Trained Staff.

Trained Staff Tracking Form

Track trained and certified staff connected to your program.

CCC Certification Courses

Find upcoming Cross Connection Control Program Administrator Certification courses.

CCC CEU Trainings

Find upcoming CEU trainings for annual certification renewal.

DDW Renewal Form

Use the state renewal form for certification renewal.

DDW Payment Portal

Pay the annual renewal fee for Cross Connection Control Program Administrators.

Element 4

Record Keeping.

Inventory Spreadsheet

Spreadsheet template for backflow inventory tracking.

Containment Protection Spreadsheet

Spreadsheet template for containment protection records.

Assembly Test Notification Letter

Sample letter for backflow assembly test notifications.

Backflow Assembly Test Report

Fillable form for backflow assembly test reporting.

Element 5

On-going Enforcement Program.

Hazard Assessment Survey Form 1

Survey form for cross connection hazard assessments.

Hazard Assessment Survey Form 2

Additional hazard assessment survey form.

Hazard Assessment Survey Form 3

Additional hazard assessment survey form.

Hazard Assessment Spreadsheet

Spreadsheet for tracking existing assemblies and possible cross connections.

Hazard Assessment Follow Up Letter

Sample follow-up letter after a hazard assessment.

Residential Customer Survey

Residential cross connection self-survey template.

Certified Backflow Testers

Search the state database of certified backflow assembly testers.

Backflow Incident Reporting

Template for reporting backflow incidents.