Gas warning notice work record: free blank PDF
Download a printable gas warning notice work record for England, Wales, Scotland, Northern Ireland. The PDF contains the record sections shown below and writing space for the actual findings.
Download the blank printable PDF for free.
Free blank Gas warning notice work record form
Print the blank record and keep the completed copy with the job. The preview shows the actual blank download.
Blank Unsafe Situation Warning Notice form
Record scope and contents
England, Wales, Scotland, Northern Ireland. The Gas Safe registered individual whose scope covers the work and safety action taken.
- Notice details: Notice reference, Date of issue, Jurisdiction, Gas supplied
- Work scope: Appliance work category
- Registered business: Registered business name, Registered business address, Registered business postcode, Registered business telephone, Business Gas Safe no.
- Gas user as stated: Gas user name, Gas user address, Gas user postcode
- Responsible person as stated: Responsible person, Responsible role, Installation address, Installation postcode
- Appliances or installations
- Classification: Unsafe category, What is unsafe, Action to make safe
- Explanation given: Explained immediate danger, Explained must not use, Explained future danger
- Actions taken: Permission given, Disconnected and sealed, Turning off removes risk, Turned off, Physical danger-label action, Label not attached, Emergency service notified, Emergency service reference
- Copies: Copy left, Emergency service contact, Gas Safe contact, Retained copy held, Owner notified
- RIDDOR decision: RIDDOR decision, RIDDOR authority, RIDDOR reference
- Responsible person receipt: Responsible person signature status, Signatory name as stated, Responsible person signature
- Engineer: Engineer name, Licence number, Engineer signature, Date signed
Primary source for this record · checked 2 October 2026
What the Gas warning notice work record covers
Record the appliance, unsafe condition, action taken, explanation and receipt, physical warning-label reference and any reporting decision. This record keeps evidence of the response; it does not replace a physical label or a required RIDDOR submission.
Who needs one
- The Gas Safe registered individual whose scope covers the work and safety action taken.
- Record scope: England, Wales, Scotland, Northern Ireland.
- Keep the completed record with the source documents, findings and job reference.
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