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Health and Safety

Executive

Health and Safety at Work etc Act 1974

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013

Report of a dangerous gas fitting

About you and your organisation

(eg building name)

(eg street)

(eg district)

Page 1 of 5


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Health and Safety

Executive

Report of a dangerous gas fitting

About the incident

*Where was the dangerous gas fitting found?

(eg building name)

(eg street)

(eg district)

*In which local authority is the address where the dangerous gas fitting was found?

Please refer to the help for guidance on the local authority

*Was it in a building?

*Was the fault repaired at the time?

*If not, were the premises made safe by disconnection or contact

with National Grid's emergency centre for them to disconnect?

*Were the premises rented?

What is the name of the person living in the premises?

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Health and Safety

Executive

Report of a dangerous gas fitting

Details of the landlord or their managing agent

(eg building name)

(eg street)

(eg district)

Was the landlord or their managing agent notified about the faults?

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Health and Safety

Executive

Report of a dangerous gas fitting

About the dangerous appliance or gas fitting

*Was an appliance or other type of gas fitting involved?

Was the appliance bought second hand?

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Health and Safety

Executive

Report of a dangerous gas fitting

About the servicing and installation of the appliance

Last service details

Who last serviced the appliance?

(eg building name)

(eg street)

(eg district)

Installer details

Name and address of the installer

(eg building name)

(eg street)

(eg district)

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.

Page 5 of 5

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