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Gas installation accident supplementary details form

This is the form you should use for providing additional details to Energy Safety for a notifiable gas accident involving an appliance or installation.

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 the Gas (Safety & Measurement) Regulations 2010. This can be done online or by printing it out and posting or faxing it to us.

Note | You must complete the fields that are marked with an asterisk *.

 

Section A
Incident details
(dd/mm/yyyy)
(e.g. 22:00)
Gas type




Accident type
Accident type
Environment
Environment
Equipment type
Equipment type
Tick all applicable and complete Section B.
Appliance
(E.g. Soundness test, odorant check, emergency services callout)
(E.g. Injuries, extent of damage, costs)
Casual factor(s)
Casual factor's
(Tick any applicable)
(To minimize the chance of recurrence elsewhere)
(Name, Contact details and Status)
(Name(s), Contact details, Occupations and Ages if relevant)
Notifier to Energy Safety
Name of person reporting the accident
(dd/mm/yyyy)
Contact(s) Who May Assist With Enquiries
(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





(Manufacturer, LAB and Serial numbers, Test date, etc)
Installation
Installation
Pipe Material
Jointing
To help us reduce spam please type the word 'installation' in the field below.
Please note

If you wish to retain a copy of this form, select first the "Generate as PDF" button to save or print a copy.

To send the form to Energy Safety select the “Submit accident details“ button. Please note that submitting the form clears all entered data, and you will no longer be able to save a copy.

Last updated 14 September 2012
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