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Backflow test report

A backflow test report for certified backflow testers and the facility managers who have to send results to the water purveyor. Record the tester's certification number and the test kit serial and calibration date, then add each location and each backflow prevention assembly there: RP, double check, pressure vacuum breaker, spill-resistant vacuum breaker or detector assembly. Scan the data plate, capture the GPS position, enter the readings as found, and record any repair and the retest. The form flags readings below the minimums you enter and a test kit past your calibration interval. It is the tester's record; the report your water purveyor asks for may have its own format.

For backflow testers, plumbing and irrigation contractors, and facility managers who look after testable assemblies for clients.

Written mainly for the US. In England and Wales choose the Water Fittings Regulations on page 1 and use it for RPZ valve compliance tests.

  • Tester certification number, test kit serial and calibration date, flagged past the interval you enter
  • Locations as spaces and each assembly as an item, with data plate scan, make, model, size, serial and GPS
  • Readings by assembly type: check valve differentials, relief valve opening point, air inlet opening
  • Readings below your local minimums flagged, with repairs, retest and final result for each assembly
  • Unprotected cross-connections, the report to the purveyor, actions and signatures
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What goes on a backflow test report?

It is useful when each assembly is identified by its serial and location, the readings are written down as found before any repair, and a failed assembly shows the repair, the parts and the retest readings. The purveyor and the owner can then see that the assembly protects the supply, not just a tick in a pass box.

Last updated . Facts checked by the SiteSurvey team on 27 October 2026 against US EPA: Cross-Connection Control Manual, EPA 816-R-03-002 (PDF), Austin Water: Backflow prevention assembly tester information, San Antonio Water System: Annual testing of backflow prevention assemblies, Water Supply (Water Fittings) Regulations 1999, Schedule 2 paragraph 15 (legislation.gov.uk) and Water Regs UK: What is meant by due date? (RPZ valve testing).

How to fill in a backflow test report

Use the test method your water purveyor or state approves. The form records the readings; the pass or fail is the tester's decision.

  1. Record the tester and kit

    Enter your certification number, the water purveyor, the owner, and the test kit serial and last calibration date with your calibration interval.

  2. Enter your minimums

    Enter the minimum readings your purveyor or state uses for RP, double check and vacuum breaker assemblies.

  3. Add each assembly

    Add each location and assembly. Scan the data plate, record the size and serial, and capture the GPS position.

  4. Test and record

    Enter the readings as found and your pass or fail. If it fails, record the repair and the retest readings.

  5. Report and sign

    Note any unprotected cross-connections, record when the report went to the purveyor, and sign with the owner.

What makes a backflow test report useful

Each assembly: readings as found, pass or fail, repair, retest readings and final result

Restaurant in Austin, 9 October. BPA-1, 1 in RP on the kitchen branch: check valve 1 at 6.4 psid, check valve 2 tight, relief valve opened at 1.2 psid against a 2.0 minimum: fail. Relief valve disc and diaphragm replaced; retest 6.6 psid, tight, relief opened at 3.1 psid: pass. Irrigation PVB passed. Test kit calibrated 12 March, 211 days ago.

Fictional example. Record the actual evidence and approved arrangements for your job.

A common recording mistake

Recording only the retest readings after a repair, so nobody can see why the assembly failed or that it failed at all.

What happens next

Send the results to the water purveyor in its format and time limit, and keep the report with the photos for the next annual test.

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Every question in the backflow test report template

A field test report for backflow prevention assemblies (RP, DC, PVB, SVB and detector assemblies). Tester certification, test kit serial and calibration date (flagged past your interval), and your local minimum readings. Each location with its assemblies: data plate scan, make, model, size and serial, GPS, protection type, initial readings by type, flags for low readings, pass or fail, repairs, retest, shut-off valves and final result. Cross-connections seen, report to the water purveyor, actions and signatures. 4 sections and 104 questions. Follow-up questions and guidance appear only when an answer calls for them, so the person on site never sees the ones that do not apply.

Make it your own: every question is editable

This is a starting point, not a fixed form. Once it is in your SiteSurvey account you can reword any question, add or remove questions, sections and answer options, and add your own logo, so it fits the way your team works and the jobs you do.

Details you only enter once

Add this form to a project in SiteSurvey and it fills in what the project already knows, so nobody on site retypes it and every form on the job uses the same names. Anything filled in can still be changed.

  • Project: the project name
  • Site address: the site address, from the space or the project
  • Client or property: the project's customer

Site, tester and test kit

  • ProjectShort answer

    Filled in from the project in SiteSurvey.

    Fills in from the project name
  • Site addressShort answer
    Fills in from the site address, from the space or the project
  • Client or propertyShort answer
    Fills in from the project's customer
  • Location (GPS)Short answer
  • Test date*Date
  • Tester*Short answer
  • Rules you test to*Choose one
    • United States: water purveyor and state rules
    • England and Wales: Water Fittings Regulations and the water undertaker
    • Other: local rules
  • Water purveyor or water undertaker*Short answer
  • Account or premises numberShort answer
  • Owner or person responsible for the assembliesShort answer
  • Owner's representative on siteShort answer
  • Owner's mailing addressNotes
  • Tester certification or licence number*Short answer
  • Issued byShort answer

    For example: state agency or certifying body.

  • Testing companyShort answer
  • GuidanceWhat this is. The tester's record of the field test of each backflow prevention assembly, with repairs and retests. It does not certify an assembly or a property. Send the results to your water purveyor in the format and time it asks for.
  • GuidanceUnited States. Your water purveyor and state set who may test, how often, the test method and the report. The US EPA Cross-Connection Control Manual says assemblies are tested by certified testers at the intervals in the local ordinance. For example, San Antonio Water System requires annual testing; Austin Water requires TCEQ-licensed testers registered with Austin Water and a test report for each assembly within five calendar days of the test.
    Shown only when the answers above make it relevant
  • GuidanceEngland and Wales. The Water Supply (Water Fittings) Regulations 1999, Schedule 2 paragraph 15: every water system has an adequate device to prevent backflow, suited to the highest fluid category downstream. Water Regs UK says RPZ valves are compliance tested at least annually, or more often if the water undertaker sets it; the undertaker sets the due date and interval.
    Shown only when the answers above make it relevant
  • Test kit labelScan a label: manufacturer, model, serial number

    Optional. Scan the data plate or label to capture the numbers.

  • Test kit make and modelShort answer
  • Test kit serial number*Short answer
  • Test kit last calibrated*Date
  • Calibration interval you work to (months)*Number

    From your water purveyor, state or certifying body.

  • Days since calibrationWorked out by the form
    Shown when “Test kit last calibrated” is answered
  • kit_cal_overWorked out by the form
  • WarningThe test kit is past the calibration interval you entered. Readings from it may not be accepted: recalibrate and retest.
    Shown only when the answers above make it relevant
  • Gauge unit*Choose one
    • psi (psid)
    • bar
  • GuidanceMinimum readings. Enter the minimums your water purveyor or state uses. The US EPA Cross-Connection Control Manual (2003) gives these field test guidelines and says local rules may amend them: RP, check valve 1 holds at least 5 psid and the relief valve opens at not less than 2 psid; double check, each check valve at least 1 psid; pressure vacuum breaker, check valve tight at 1 psid and air inlet opens at a minimum of 1 psi.
  • RP: check valve 1 minimumNumber
  • RP: relief valve opening minimumNumber
  • Double check: each check valve minimumNumber
  • Vacuum breaker: air inlet opening minimumNumber
  • Vacuum breaker: check valve minimumNumber

Assemblies and test results

  • GuidanceAdd each location, then each assembly there. Scan the data plate, record the readings as found, then any repair and the retest. The pass or fail is your decision as the tester, under your local rules; the form flags readings below the minimums you entered.
  • Locations
    Repeat for each entry. Each one asks:
    • Location*Short answer

      For example: Restaurant domestic service; Irrigation, front landscaping.

    • Assemblies at this location
      Repeat for each entry. Each one asks:
      • Assembly ID or purveyor's number*Short answer
      • Assembly type*Choose one
        • RP: reduced pressure principle
        • DC: double check valve
        • PVB: pressure vacuum breaker
        • SVB: spill-resistant vacuum breaker
        • RPDA: reduced pressure detector
        • DCDA: double check detector
        • Other
      • Assembly data plateScan a label: manufacturer, model, size, serial number

        Optional. Scan the data plate or label to capture the numbers.

      • ManufacturerShort answer
      • ModelShort answer
      • SizeShort answer

        For example: 3/4 in; 2 in.

      • Serial number*Short answer
      • Assembly location (GPS)Short answer
      • Where it isShort answer

        For example: below grade in the meter box at the front kerb; mechanical room, east wall.

      • Type of protectionChoose one
        • Containment (at the service connection)
        • Isolation (internal, at a fixture or process)
        • Irrigation
        • Fire line
        • Other
      • What it protects againstShort answer

        The cause requiring protection, for example: soda dispensers and chemical dosing; irrigation with fertiliser injection.

      • Reason for the testChoose one
        • Annual test
        • New installation
        • After repair or relocation
        • Requested by the water purveyor
        • Other
      • GuidanceInitial test. Enter the readings as found, before any repair.
      • Check valve 1 differentialNumber

        Reading on the differential gauge, in the unit on page 1.

        Shown only when the answers above make it relevant
      • Check valve 1Choose one
        • Closed tight
        • Leaked
        • Not tested
        Shown only when the answers above make it relevant
      • Check valve 2 differentialNumber
        Shown only when the answers above make it relevant
      • Check valve 2Choose one

        RP: tight against backpressure.

        • Closed tight
        • Leaked
        • Not tested
        Shown only when the answers above make it relevant
      • Relief valve opened at (differential)Number
        Shown only when the answers above make it relevant
      • Relief valve openedYes or No
        Shown only when the answers above make it relevant
      • Air inlet opened atNumber
        Shown only when the answers above make it relevant
      • Air inlet openedYes or No
        Shown only when the answers above make it relevant
      • Check valve differentialNumber
        Shown only when the answers above make it relevant
      • No. 2 shut-off valveChoose one
        • Closed tight
        • Leaked
        • Not tested
        Shown only when the answers above make it relevant
      • a_low_firstWorked out by the form
      • CheckOne or more readings are below the minimums entered on page 1, or a valve leaked or did not open.
        Shown only when the answers above make it relevant
      • Initial test result*Choose one
        • Pass
        • Fail
      • Repairs made and parts used*Notes
        Shown when “Initial test result” is “Fail”
      • GuidanceRetest after repair.
        Shown when “Initial test result” is “Fail”
      • Check valve 1 differentialNumber

        Reading on the differential gauge, in the unit on page 1.

        Shown only when the answers above make it relevant
      • Check valve 1Choose one
        • Closed tight
        • Leaked
        • Not tested
        Shown only when the answers above make it relevant
      • Check valve 2 differentialNumber
        Shown only when the answers above make it relevant
      • Check valve 2Choose one

        RP: tight against backpressure.

        • Closed tight
        • Leaked
        • Not tested
        Shown only when the answers above make it relevant
      • Relief valve opened at (differential)Number
        Shown only when the answers above make it relevant
      • Relief valve openedYes or No
        Shown only when the answers above make it relevant
      • Air inlet opened atNumber
        Shown only when the answers above make it relevant
      • Air inlet openedYes or No
        Shown only when the answers above make it relevant
      • Check valve differentialNumber
        Shown only when the answers above make it relevant
      • No. 2 shut-off valveChoose one
        • Closed tight
        • Leaked
        • Not tested
        Shown only when the answers above make it relevant
      • a_low_retestWorked out by the form
      • CheckA retest reading is below the minimums entered on page 1, or a valve leaked or did not open.
        Shown only when the answers above make it relevant
      • No. 1 shut-off valve operates and is tightChoose one
        • Closed tight
        • Leaked
        • Not tested
      • Final result*Choose one
        • Pass
        • Fail: not repaired
        • Removed or replaced
      • WarningAssembly left failed. Tell the owner and the water purveyor as your rules require, and record what protects the supply until it is repaired.
        Shown when “Final result” is “Fail: not repaired”
      • NotesNotes
      • Photos (data plate, installation, gauge readings, repairs)Photos
      • a_first_failWorked out by the form
      • a_final_failWorked out by the form
      • a_sov_leakWorked out by the form
      • Assembly resultWorked out by the form
    • l_countWorked out by the form
    • l_first_failWorked out by the form
    • l_final_failWorked out by the form
    • l_sovWorked out by the form
  • Assemblies testedWorked out by the form
  • Failed the initial testWorked out by the form
  • Left failedWorked out by the form
  • No. 1 shut-off valves leakingWorked out by the form

Cross-connections and the report

  • Any unprotected cross-connections or unapproved installations seen?*Yes or No
  • What and where*Notes
    Shown when “Any unprotected cross-connections or unapproved installations seen?” is Yes
  • PhotosPhotos
    Shown when “Any unprotected cross-connections or unapproved installations seen?” is Yes
  • Report due to the water purveyor byDate

    From your purveyor's rules.

  • Report submitted to the purveyorYes or No
  • Submission referenceShort answer
    Shown when “Report submitted to the purveyor” is Yes
  • xc_flagWorked out by the form

Result, actions and signatures

  • Items needing actionWorked out by the form
  • ResultWorked out by the form
  • Actions
    Repeat for each action. Each one asks:
    • Action*Notes
    • PriorityChoose one
      • Now: supply unprotected
      • Within 7 days
      • Within 30 days
      • At the next test
    • Who will do it*Short answer
    • Due byDate
    • Status*Choose one
      • Open
      • In progress
      • Done, checked
    • Photo when donePhotos
      Shown when “Status” is “Done, checked”
  • Actions still openWorked out by the form
  • Decision*Choose one
    • All assemblies passed
    • Passed after repair and retest
    • One or more assemblies left failed
  • Next test dueDate
  • Summary for the clientNotes
  • Tester nameShort answer
  • Tester signature*Signature
  • Owner or representative nameShort answer
  • Owner or representative signatureSignature

See it filled in

A completed backflow test report report, made by SiteSurvey from a fictional site visit: every answer, the photos, the guidance that applied and the sign-off, ready to send as a PDF.

See completed form (PDF) ↗

Backflow test report FAQs

How often do backflow preventers need testing?

Your water purveyor and state decide. The US EPA Cross-Connection Control Manual says testable devices are tested by certified testers at the intervals in the local ordinance. Many programs require an annual test: San Antonio Water System, for example, requires annual testing of backflow prevention assemblies. In England and Wales, Water Regs UK says RPZ valves are compliance tested at least annually, or more often if the water undertaker sets it.

Sources: US EPA: Cross-Connection Control Manual, EPA 816-R-03-002 (PDF), San Antonio Water System: Annual testing of backflow prevention assemblies and Water Regs UK: What is meant by due date? (RPZ valve testing).

What readings should an RP assembly pass?

Use the criteria your purveyor or state sets. The US EPA manual gives these field test guidelines and says local jurisdictions may amend them: the first check valve holds at least 5 psid, the second check valve is tight against backpressure, and the relief valve opens at not less than 2 psid. The form takes the minimums you enter and flags readings below them.

Source: US EPA: Cross-Connection Control Manual, EPA 816-R-03-002 (PDF).

What about double check and pressure vacuum breaker assemblies?

In the EPA manual's test procedures, each check valve of a double check assembly should hold a minimum of 1 psid, and a pressure vacuum breaker's check valve is tight at 1 psid with the air inlet opening at a minimum of 1 psi. Local rules may differ, so enter your own minimums on page 1.

Source: US EPA: Cross-Connection Control Manual, EPA 816-R-03-002 (PDF).

Does the test kit need to be calibrated?

Yes. The EPA manual says test equipment should be periodically checked for calibration, and Austin Water requires gauges calibrated by an approved gauge testing company. The interval comes from your purveyor or state. Enter the calibration date and interval and the form warns you when the kit is past it.

Sources: US EPA: Cross-Connection Control Manual, EPA 816-R-03-002 (PDF) and Austin Water: Backflow prevention assembly tester information.

What happens when an assembly fails?

It is repaired or replaced and retested. San Antonio Water System says an assembly that is not operating satisfactorily must be repaired and then retested by the tester. The form records the initial readings, the repair and parts, the retest readings and the final result, and counts assemblies left failed.

Source: San Antonio Water System: Annual testing of backflow prevention assemblies.

Is this the official test form for my water utility?

Not necessarily. Many purveyors want results on their own form or online system. Use this as your field record with photos and GPS, then copy the results into the purveyor's report. It does not certify an assembly. In England and Wales the Water Fittings Regulations, Schedule 2 paragraph 15, require adequate backflow prevention suited to the fluid category downstream.

Sources: Austin Water: Backflow prevention assembly tester information and Water Supply (Water Fittings) Regulations 1999, Schedule 2 paragraph 15 (legislation.gov.uk).

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