Health and Safety
Health and Safety at Work etc Act 1974
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
Report of a gas-related injury
A report of a flammable gas incident will ask for the number of injured persons and their names.
You will need this information to complete and submit the form.
About you and your organisation
*Your Phone No
Address Line 1
(eg building name)
Address Line 2
Address Line 3
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About the gas incident
*On what date did the incident happen?
*What was the main cause of the incident?
Exposure (to carbon monoxide)
Other exposure (e.g. to unburnt gas)
Fire or explosion
*Where did the incident happen?
*In which local authority did the incident happen?
Please refer to the help for guidance on the local authority
*Was it in a building?
If yes, what type of building
And in what room?
*Were the premises rented?
What is the name of the person living in the premises?
*Is the resident contactable?
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Details of the landlord or their managing agent
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Contact details of someone other than the resident
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About those injured as a result of the incident
*How many people died?
*How many people suffered major injury?
People injured as a result of the incident
List of injured person(s)
*Describe what happened
Please check your email address below. Ensure that you change if incorrect as this is the email address that
your acknowledgement and a copy of the form will be sent to.
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