Title Page

  • Audit Title

  • Conducted on

  • ENSURE CORRECT DATE, TIME AND COMPLETION DETAILS ARE RECORDED, AS THEY WILL IMPACT THE ENGINEER'S PAY IF RECORDED INCORRECTLY.

CUSTOMER DETAILS

  • Title:

  • Name: (Inc Initials)

  • Job Address: (edit address manually if displayed incorrectly)
  • Telephone Number:

  • Work Order No:

  • PEMS INDICATOR

RESOURCE INFORMATION

  • NAME:

  • PAYROLL NO:

  • CONTACT NUMBER:

VISIT DETAILS

  • TIME ISSUED:

  • TIME ONRT:

  • TIME ONST:

  • TIME TEAM REQUIRED:

  • TIME COMPLETED:

JOB COMPLETION CODES FOR EMERGENCY WORK ONLY

  • JOC 1

  • JOC 2

  • JOC 3

WORK REPORT

  • PLEASE ENTER WORK REPORT (WORK COMPLETED ON SITE):

WORK COMPLETION REASON

  • Please Select Response

MANDATORY DATA FORM - STATUS OF SUPPLY

  • Status of Supply:

  • GAS OFF TIME: (only enter if applicable)

  • Final Tightness Test Carried Out?

  • Outlet Pipe Repaired?

  • Did You Work on Meter or Installation?

  • Number of Storeys in Building:

REPORT INDICATORS

  • RIDDOR:

  • ALLEGED THEFT OF GAS:

  • Did You Check/Work on Appliance/Installation Pipework?

  • CROSS BONDING:

  • SUPPLIER SAFETY CHECK:

  • REASON IF (NO) ENTERED ABOVE:

  • SAFETY NOTICE ISSUED:

  • INDEPENDENT GT (IGT):

  • RIGHTS OF ENTRY - REG 5:

  • EMERGENCY SERVICES ON SITE?

  • INCIDENT NUMBER IF (YES) ENTERED ABOVE:

APPLIANCE/INSTALLATION INFORMATION

  • APPLIANCE/INSTALLATION INFORMATION

  • Appliance/Installation
  • APPLIANCE TYPE:

  • APPLIANCE LOCATION:

  • APPLIANCE STATE:

  • DISCONNECTED:

  • VISUAL CHECK AND RELIGHT ONLY:

  • FLUE SATISFACTORY:

  • VENTILATION SATISFACTORY:

  • DANGEROUS APPLIANCE INSTALLATION LABEL ATTACHED:

APPLIANCE DELIVERY

  • Reason For Leaving Appliance:

  • Reason For Non Delivery:

  • E15 Reference Number:

SITE REPORT

  • SUSPECTED SOURCE OF ESCAPE:

  • GAS IN PROPERTY:

  • DAMAGE CAUSED BY THIRD PARTY:

  • Enter Comments If (YES) Entered Above:

  • HAS EXCAVATION BEEN LEFT VENTING:

  • Current Visit's HIGHEST % LEL:

  • NOT INVOLVING NATURAL GAS:

  • IS GAS ESCAPE STOPPED:

  • IF ENTERED (YES) ABOVE - PLEASE INDICATE GAS STOPPED DATE AND TIME:

  • GAS AT ECV DATE AND TIME:

  • HAS GAS BEEN INTERRUPTED:

  • IF ENTERED (YES) ABOVE - PLEASE INDICATE GAS INTERRUPTION DATE AND TIME:

  • INTERRUPTION CATEGORY:

  • INTERRUPTION REASON:

  • PART of INCIDENT? (>250 properties):

  • THIS SECTION ONLY TO BE COMPLETED IF ESCAPE IS POOR PRESSURE OR WATER INGRESS

  • Vulnerable Customer:

  • More Than 2 Properties Affected:

  • Is Supply Isolated:

  • STANDING PRESSURE (mBar):

  • WORKING PRESSURE (mBar):

RISK SCORE FORM

  • PRESSURE:

  • MATERIAL:

  • GAS IN DUCTS:

  • NUMBER OF PUBLIC BAR HOLES MADE:

  • NUMBER OF PRIVATE BAR HOLES MADE:

  • HIGHEST Reading and Distance (M) from PROPERTY (GIA/LEL):

  • NEAREST Reading and Distance (M) from PROPERTY (GIA/LEL):

  • GROUND CONDITION:

  • SIZE OF MAIN:

  • PROXIMITY OF MAIN:

  • RISK SCORE:

  • COMMENTS:

IGT INTERNAL CHARGEABLE WORK

  • IGT REFERENCE NUMBER:

  • NETWORK:

  • Contact Details:

  • Site Contact Name:

  • Job Address: (edit address manually if displayed incorrectly, include any Flat Numbers)
  • Work Details:

  • Are plans on site:

  • Work Type:

  • Manager On Site:

  • Scenario:

  • List of fittings used:

  • FCO TO SIGN DOCUMENT AS COMPLETE:

FOR MI PURPOSES WHEN MANUAL (DETAILS OF THE PERSON CARRYING OUT THE WORK RECOVERY) NOT TO BE COMPLETED BY THE FCO

  • NAME:

  • DATE:

  • TIME:

  • JOB RECEIPT TIME:

  • JOB CLASSIFICATION (Please Circle): P1 P2

  • JOB IN STANDARD (Please Circle): YES NO

  • Masternaut / Voice / System (Please Circle): On Site Time:

  • Network (Please Circle): NW WM EM EA NL

  • PLEASE ENTER TYPE OF JOB: e.g. Internal/External...

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.