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

Date of incident ■

(dd/mm/yyyy)

Time of incident ■

(e.g. 22:00)

Address and/or exact location ■

Gas type ■

LPG
Natural
Reticulated LPG
Biogas

Accident type

Fire

Gas leak or escape

Explosion

CO Poisoning (Incomplete combustion)

Overheating

Other accident type (specify)

Environment

Building

Outside

Caravan/Mobile home

Car, Van or Truck

Other environment (specify)

Equipment type

Tick all applicable and complete Section B.

Commercial or Industrial

Container

Installation Pipework

Other equipment type

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)

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 ■

Name of person reporting the accident

Telephone ■

Email ■

Date notified ■

(dd/mm/yyyy)

Address

Contact(s) Who May Assist With Enquiries

Contact's who may assist with enquiries

Contact Telephone

Contact Facsimile

Other Report(s)

(Name(s) and Contact details)

Section B

Gas Equipment Details (Complete relevant boxes)

Appliance

Make

Model/Serial No

Manufacturer

Installer

Certifier

Last Service Details

Rating (ouput, pressure, etc)

Date Installed or Purchased

(dd/mm/yyyy)

Manufacture Date or Age of Appliance

(dd/mm/yyyy)

Container or Portable LPG

Regulator Fitted

Yes
No

Container Type

Refillable
Disposable

Connection Type

Quick-Fit (Clip-on)
Q.C.C.
Screwed by Spanner
Screwed by Hand - No Spring Loading
Screwed by Hand - Spring Loading

Other Connection Type

NETT LPG Capacity of Container

Adapter Details (marking or type)

Regulator Details (make and markings)

Container and Valve Details

(Manufacturer, LAB and Serial numbers, Test date, etc)

Verification: Please type the word 'installation' ■

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.

Generate as PDF

Online forms for detailing notified events

Gas installation accident supplementary details form