If this case relates to an escape of a flammable gas that meets the criteria of Schedule 2 Part 1 Section 19, then please use the Dangerous Occurrence form (Report a Dangerous Occurrence NI2508). If this case relates to a flammable gas incident causing death or a major injury then please contact HSENI directly on 0800 0320 121 to report it.
PART A
About you and your organisation
Title:
[choose]
Firstname: 
Surname: 
Telephone: 
Job Title: 
Organisation Name: 
Postcode:  
If you don't live in Northern Ireland, or you can't find your address, enter your address below.
Property:
Street: 
Locality:
Town: 
County: 
Email:  
 
PART B
Some general details
When was the dangerous gas fitting found?
Date:  
Time:
What is the address and postcode at which it was found?
Postcode:  
If you don't live in Northern Ireland, or you can't find your address, enter your address below.
Property:
Street: 
Locality:
Town: 
County:  
Are the premises rented?
[choose]
If Yes selected, enter the details of the landlord/managing agents.
Name:
Postcode:   
Property:
Street:  
Locality:
Town:  
County: 
Telephone:
Was the landlord (or the managing agent for the premises) notified about the faults:
Did Incident happen in a building?: 
[choose]
What type of building?:
HOUSE
What type of room?:
KITCHEN
Was the fault repaired at the time?
Fault repaired: 
If not was the situation made safe by disconnection or contact with the providers emergency centre for them to disconnect.
Disconnected: 
PART C
About the person
What was the name of the person living in the premises? (If they cannot be contacted, give the name, address and telephone number of a relative or friend)
Title:
[choose]
Firstname:  
Surname: 
Postcode:  
If you don't live in Northern Ireland, or you can't find your address, enter your address below.
Property:
Street: 
Locality:
Town:  
County: 
Telephone:  
 
PART D
About the dangerous gas fitting
What was the main fault?
Main fault:
Gas Leak
What type of appliance was Involved?
Appliance:
NOT KNOWN
What type of gas was Involved?
Gas type:
[choose]
Was the appliance?
Flue type:
[choose]
Was the appliance bought second hand (if known)?
Second hand:
[choose]
Summary of the dangerous gas fitting
Please say how dangerous you consider it to be, and why/what action you have taken to make things safe eg. Repairing, disconnection gas supply, advising occupiers (or landlords/managing agents) or reporting to the gas provider.
Summary:
PART E
About the servicing and Installation of the appliance/gas fitting
Do you know who last serviced the appliance?
Service:
Date:
Company:
Title:
[choose]
Firstname:
Surname:
Postcode:   
Property:
Street:
Locality:
Town:
County:
Phone Number:
Do you know who Installed the appliances/gas fitting?
Installation:
Date:
Company:
Title:
[choose]
Firstname:
Surname:
Postcode:  
Property:
Street:
Locality:
Town:
County:
Phone Number:
PART F
Submitter
If submitting this on line, 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.
Email: