Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

CUSTOMER DETAILS

  • Title:

  • Name: (Inc Initials)

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

  • Work Order No:

RESOURCE INFORMATION

  • NAME:

  • PAYROLL NO:

  • CONTACT NUMBER:

VISIT DETAILS

  • TIME ISSUED:

  • TIME ONRT:

  • TIME ONST:

  • TIME COMPLETED:

JOB COMPLETION CODES FOR M1 METER WORK ONLY (SELECT ONE JOC PER RESPONSE) IF M2 WORK SELECT N/A IN EACH JOC BOX AND MOVE ONTO JOB COMPLETION CODES FOR M2 METER WORK BELOW.

  • JOC 1

  • JOC 2

  • JOC 3

JOB COMPLETION CODES FOR M2 METER WORK ONLY (SELECT ONE JOC PER RESPONSE) IF M1 METER WORK SELECT N/A IN EACH JOC BOX AND MOVE ONTO JOB COMPLETION CODES FOR M1 METER WORK ABOVE.

  • JOC 1

  • JOC 2

  • JOC 3

WORK COMPLETION REASON

  • Please Select Response

MANDATORY DATA FORM - STATUS OF SUPPLY

  • Status of Supply:

  • GAS OFF TIME: (only enter if applicable)

  • Outlet Pipe Repaired?

  • Final Tightness Test Carried Out?

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

  • Supplier Safety Check Carried Out?

  • Number of Storeys in Building:

  • 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:

EXISTING/REMOVED METER DETAILS

  • LOCATION:

  • MAKE:

  • MODEL:

  • SERIAL NUMBER:

  • YEAR of MANUFACTURE:

  • METRIC/IMPERIAL:

  • STATUS:

  • INDEX:

  • SYN/ULTRA/ROT:

  • CONDITION:

  • THIRD PARTY METER:

INSTALLED NEW METER DETAILS

  • LOCATION:

  • MAKE:

  • MODEL:

  • SERIAL NUMBER:

  • YEAR of MANUFACTURE:

  • METRIC/IMPERIAL:

  • STATUS:

  • INDEX:

  • SYN/ULTRA/ROT:

  • CONDITION:

  • BATTERY DETAILS:

EXISTING/REMOVED REGULATOR DETAILS

  • MAKE:

  • MODEL:

  • SERIAL/BATCH NUMBER PRESENT?

  • IF YES ENTER DETAILS:

  • IF NO STATE REASON WHY NO DETAILS ENTERED:

INSTALLED REGULATOR DETAILS

  • MAKE:

  • MODEL:

  • SERIAL/BATCH NUMBER:

  • 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): M1 M2

  • JOB IN STANDARD (Please Circle): YES NO

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

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

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.