Information

  • Customer name

  • Customers Address
  • Job Number

  • Conducted on

  • H.S.A name

Survey checks

  • Has the mains water pressure been tested?

  • Flow rate & time of test

  • Is there any Asbestos present in the property

  • Is a sample required?

  • Has the Socket and See passed?

  • Socket and See readings

  • Is the existing shower compatible?

  • Has the customer been advised of one tap operation?

Installation type & Boiler

  • Type of installation?

  • What boiler is being installed?

  • Will boiler clearances met?

  • Add media

  • Notes on boiler

Flue

  • Type of Flue?

  • What is the equivalent flue length?

  • Is 125mm flue required?

  • Number of elbows and extensions?

  • Have all flue clearances been checked?

  • Is an internal fix required?

  • Is a terminal guard required?

  • Is a plume kit required

  • What plume extensions and elbows are required?

  • Has pluming been explained to the customer?

  • Flue

  • Notes on flue

Condense

  • Where is the condense terminating?

  • If external what colour pipe is required?

  • Is a soak away required?

  • Is a condense pump required?

  • Is the condense terminating into a foul drain?

  • Condense

  • Notes on condense route

System Design

  • Is the cold feed and open vent configured correctly?

  • Does the system need to be sealed?

  • Is the system fully pumped?

  • Does the customer want new radiator valves?

  • Are we changing or adding any radiators?

  • If yes what size and location of radiators?

  • Has an auto bypass been fitted?

  • Are we replacing any existing components?

  • What type of cylinder are we fitting?

  • System

  • System notes

Gas pipework

  • Is a new gas run required?

  • Length of gas run?

  • Size of pipework for gas run?

  • Notes on gas run

Water pipework

  • Number of lengths of pipe for hot and cold supplies

  • Hot and cold supply notes

  • Number of lengths of pipe for heating pipework?

  • Heating pipework notes

System Controls

  • What thermostat does the customer want?

  • What time control does the customer want?

  • Does the cylinder stat need replacing?

  • Does the system need frost protection?

  • Notes on system controls

Powerflush and system performance

  • Has the customer had any issues with the system?

  • Does the system require a power Flush?

  • Number of radiators on system?

Building work, Manual Handling & Working at Heights

  • Does the installation require scaffolding?

  • What size scaffolding is required?

  • Scaffold Location

  • Notes on Scaffolding

  • Is Specialist Building work required?

  • Is boxing required?

  • How many specialist build hours required?

  • Specialist building work

  • Notes on specialist building work

  • Is a double handed lift required?

  • Is there restricted access?

  • Is loft boarding and lighting required?

Electrical

  • Is a new fused spur required?

  • Does the boiler require a pump over run?

  • Is there PEB at all services?

  • Notes on electrics

Disconnect and remove

  • What are we removing?

  • Are we disconnecting anything and leaving it in place?

  • Notes on removals

Extras

  • What extras does the customer want?

  • Notes on extras

  • Is route clearance required?

  • Other Notes/Disruption

  • H.S.A Signature

  • Customer Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.