What is the backflow test report form template?
Backflow prevention assemblies get tested on a cycle, and every test produces the same handful of facts: the device, where it sits, the pressures across each check valve, and a result. Water suppliers, property managers and the owners themselves all want that record, and they want it to be legible.
This template fits a backflow test on a single page. The tester's certification number and test kit come first, then the property, the assembly and its location. The readings section covers line pressure, both check valves, the air inlet on vacuum breakers, and the relief valve opening point, which appears only when a reduced pressure assembly is selected. A fail result opens the repair and retest questions, so a failed device and its fix sit on the same report.
Each completed test becomes a PDF in your FileIt vault. Keep the reports by customer or by account number, and the history of every assembly you test is in one place when the next cycle comes round.
- Best for
- Certified backflow testers, plumbing companies, fire-protection contractors and property managers
- Filled in by
- The tester, at the assembly
- Time to complete
- About 4–6 minutes
- Includes
- Kit calibration date, readings, pass or fail, repairs, retest, tester signature
Who uses a backflow test report form?
- An annual test on a reduced pressure assembly protecting a restaurant's water supply
- A first test after a double check valve is installed on a new fire line
- A retest after cleaning and rebuilding a check valve that failed last week
- Testing irrigation vacuum breakers across a school campus in one morning
- Answering a water supplier's notice that a test is due
- A property manager keeping test records for every building in a portfolio
Questions on this backflow test report form
32 questions · includes signature, conditional questions, consent checkbox.
1 Backflow test
- Tester*
- Tester certification number*
- Certification expires
- Test kit serial number
- Test kit last calibrated
- Test date*
- Reason for test* Annual test · New installation · After repair · Water supplier notice · Relocated assembly
- Property owner or account name*
- Water account number
- Service address*
- Where the assembly is on site*
- Assembly type* Reduced pressure zone (RP / RPZ) · Double check valve (DC) · Pressure vacuum breaker (PVB) · Spill-resistant vacuum breaker (SVB) · Double check detector assembly (DCDA) · Reduced pressure detector assembly (RPDA)
- Make
- Model
- Serial number
- Size ½ in · ¾ in · 1 in · 1¼ in · 1½ in · 2 in · 2½ in · 3 in · 4 in · 6 in · 8 in · 10 in
- Protecting Domestic supply · Fire line · Irrigation · Process or equipment
- Line pressure (psi)
- Check valve 1 — held at (psid)
- Check valve 2 — held at (psid)
- Relief valve opened at (psid) asked only when it applies
- Air inlet opened at (psid)
- Shut-off valves Both close tight · No. 1 leaking · No. 2 leaking · Both leaking
- Initial test result* Pass · Fail
- What failed?* asked only when it applies
- Repairs made asked only when it applies Cleaned check valve 1 · Replaced check 1 disc or spring · Cleaned check valve 2 · Replaced check 2 disc or spring · Replaced relief valve parts · Replaced a shut-off valve · Full repair kit installed · No repair today
- Parts used asked only when it applies
- Retest* asked only when it applies Passed after repair · Still failing · Not retested today
- Retest date or due by asked only when it applies
- Notes
- Tester declaration*
- Tester signature*
The backflow test report form, page by page
1 Tester, property & assembly
The form opens with the Tester, their Tester certification number and the date the Certification expires, then the Test kit serial number and when the Test kit last calibrated. Test date and Reason for test follow — an annual test, a new installation, after repair, a water supplier notice, or a relocated assembly.
The Property owner or account name, Water account number and Service address identify the site, and "Where the assembly is on site" pins down the device itself. Assembly type covers RP, double check, pressure and spill-resistant vacuum breakers, and both detector assemblies, with Make, Model, Serial number and Size beside it. "Protecting" notes whether it serves a domestic supply, a fire line, irrigation or process equipment.
2 Readings, result & repairs
Under Readings, the tester records Line pressure (psi), "Check valve 1 — held at (psid)", "Check valve 2 — held at (psid)" and "Air inlet opened at (psid)" for vacuum breakers. "Relief valve opened at (psid)" appears only for a reduced pressure zone assembly. A Shut-off valves question records whether both close tight.
Initial test result is pass or fail. A fail asks "What failed?" and opens Repairs made (cleaning or replacing parts in either check, relief valve parts, a shut-off valve, a full repair kit, or no repair today), Parts used, a required Retest answer and the retest date. The page ends with notes, a short tester declaration and the tester's signature.
Make the template yours
- Add your water supplier's own reference fields, such as a cross-connection ID, to the property section
- Change the size list to the assemblies you actually test
- Add the supplier's email address to notifications if they accept test reports that way
- Make the water account number required if your customers are billed by account
- Set up one form per large customer so their reports file into their own vault folder
- Reword the tester declaration to match the wording your area uses
Tips for a better backflow test report form
- Record readings to one decimal place, the way your gauge shows them
- Note the kit calibration date every time — it's the first thing anyone checks on a disputed result
- Describe the assembly's location well enough that a different tester can find it next year
- Retest before you leave whenever you can, so the report closes with a pass
- Photograph the nameplate if the serial number is hard to read
- Use the notes for access issues, like a locked vault or a meter pit full of water
Every response becomes a PDF in your vault
Each test is filed as a PDF in your FileIt vault, named with the test date, and the account owner is notified. Add the property owner's or water supplier's address to the notification emails in settings if they should hear about every test.
From the Responses table you can filter for fails that still need a retest and export the test dates to CSV, which makes planning next year's round of tests much quicker.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Backflow test report form: frequently asked questions
Is this backflow test report template free?
Yes. It's part of the Forms app on every FileIt account, including the free plan.
Which assembly types does it cover?
Reduced pressure zone, double check, pressure vacuum breaker, spill-resistant vacuum breaker, and double check and reduced pressure detector assemblies.
Why does the relief valve reading only appear sometimes?
It shows when you choose a reduced pressure zone assembly, the type that has a relief valve. You can change that rule in the designer.
What happens if the device fails?
Choose Fail and the form asks what failed, which repairs you made, the parts used and whether a retest passed.
Will my water supplier accept this report?
Suppliers set their own requirements, so check what yours asks for. You can add any extra fields they need in the designer.
Can I track my own certification expiry?
The report records it on each test. Many testers also keep their certificate in their FileIt vault so they get a reminder before it expires.