Fillable Report of flammable gas incidents (Dental Law & Ethics)

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Report of flammable gas incidents (Dental Law & Ethics)

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Health and Safety at Work etc Act 1974
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
Report of flammable gas incidents
F2508G1 (rev 04.99)
Explanatory notes
1. This form should be used to report to HSE incidents that have arisen from the use of either natural gas or liquefied petroleum
gas (LPG) and have caused fatal or major injuries* to gas consumers either through the acute symptoms of carbon monoxide
poisoning or the effects of fires or explosions after gas escapes have occurred.
* Major injuries include any that have led to unconsciousness, or the need for hospitalisation for more than 24 hours.
2. Form F2508G2 should be used to report gas appliances or installations that are regarded to be dangerous after examination or
test, but have not actually led to deaths or major injuries.
3. Form F2508 should be used to report any deaths or major injuries arising from the use of gas involving persons whilst at work.
Part A
About you and your organisation
1. What is your full name?
2. What is your job title?
3. What is the name of your organisation?
4. How can we contact you if we need more information about
the incident?
Your address and post code
Your telephone/fax number
Part B
About the incident
1. What was the main cause of the incident?
■■
exposure (to carbon monoxide)?
■■
other exposure (eg to unburnt gas)?
■■
fire or explosion?
2. Where did the incident happen?
Address and post code
3. Did the incident happen in a building?
■■ no
■■ yes - what type of building?
■■ house
■■ flats (four storeys or less)
■■ flats (more than four storeys)
■■ bungalow
■■ maisonette
■■ other
What type of room?
■■ kitchen
■■
bathroom
■■ bedroom
■■ lounge
■■
dining room
■■ other room
4. When did the incident happen?
5. What is the name of the person living in the premises? (if
they cannot be contacted, please give the name address
and telephone number of a relative or friend who can)
6. Were the premises rented?
■■
yes
■■
no
If so, what is the name, address and telephone number of
the landlord or their managing agent?
7. How many people died?
How many suffered major injuries?
8. Please give details of the people who died or suffered
major injuries.
Part D
Your signature
Signature
Date
Please send this form to:
Incident Contact Centre, Caerphilly Business Centre,
Caerphilly Business Park, Caerphilly, CF83 3GG.
or email to riddor@connaught.plc.uk
or fax to 0845 300 99 24
Part C
Summary of incident
Please give a summary of the incident. If possible include any
known details of police involvement, hospitals to which affected
persons have been sent, and the gas supplier for the premises.
For official use
Client number Location number Event number
■■
INV REP
■■
Y
■■
N
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Report of flammable gas incidents (Dental Law & Ethics)

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Completed 19 April 2021

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