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Gas Appliance/ Installation Incident or Accident Supplementary Details Form


If you would like to report a notifiable gas accident, you should complete the Event Notification Form which will go directly into the Energy Safety Intelligence database. This form below has been provided to allow notifiers to provide additional accident details as required by regulation 33 of the Gas Regulations 1993. This can be done online or by printing it out and posting or faxing it to us.

If you wish to retain a copy, print the form first (use "Save as PDF") and then to send it to Energy Safety (by pressing "Submit"). Submitting the form blanks the fields.

* indicates a mandatory field

Section A

Incident Details
(dd/mm/yyyy)
 
(e.g. 22:00)
 
 
Gas type
 
Accident type


 
Environment

 
Losses involved?

 
Equipment type
Tick all applicable and complete Section B.
 

 
Appliance










 
CNG Station
Summary description of events surrounding incident or accident *
 
Actions to ensure safety at scene
(E.g. Soundness test, odorant check, emergency services callout)
 
Description of loss *
(E.g. Injuries, extent of damage, costs)
 
Casual factor(s)
(Tick any applicable)
















 
 
Remedial Action Taken or Recommended
(To minimize the chance of recurrence elsewhere)
 
Owner & User or Person Working on/near Equipment
(Name, Contact details and status)
 
Person(s) Affected by Loss
(Name(s), Contact details, Occupations and Ages if relevant)
 
Notifier to Energy Safety *
(Name(s) and Contact details)
 
(dd/mm/yyyy)
Contact(s) Who May Assist With Enquiries
 


 
Other Report(s)
(Name(s) and Contact details)
 

Section B

Gas Equipment Details (Complete Relevant boxes)
 
Appliance
 
 
 
 
 
 
 
(dd/mm/yyyy)
 
(dd/mm/yyyy)
 
Container or Portable LPG
Regulator Fitted
 
Container Type
 
Connection Type




 
 
 
 
 
Installation
Installation



 
Pipe Material
 
Jointing
 
CNG Station
 
Storage Vessel
(dd/mm/yyyy)
 
 
(dd/mm/yyyy)
 
Compressor
 
 
(dd/mm/yyyy)
 
Dispenser
 
 
Semiconducting
 

Caution: Submitting the form blanks the fields. If you wish to print the form (from "Save as PDF") and submit it on-line you should print it first.

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