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Painter Decorator - The W1nners' Club

1.    About the person who had the accident:

Name: Bill Thompson
Address: 65 Wingrove Avenue, Meltham, Huddersfield,
Postcode: HD9 4RT
Occupation: Painter Decorator

2.    About you the person filling in this record:

Complete if you did not have the accident:
Name: Next door neighbour (not my real name obviously).
Address: 89 Brookbank Terrace, Honley, Huddersfield
Postcode: HD9 6YT
Occupation: I work in the steal industry with a speciality for gaining entry to buildings!

3.    About the accident:

Say when it happened:
Date: 26/01/2018 Time: 09:00am
Say where it happened (which room or place):
See picture attached
Say how it happened (include the cause if you can):
I’m not sure exactly. All I know is that Mrs Grady at number 12 asked me to take a picture of the work that had been done so far on her balcony so that she could send it to her daughter who moved to Australia a couple of years ago. Next thing I know – the phone rang and Mrs. Grady went to answer it as she was expecting a call from her daughter!
Say if the person who had the accident suffered any injury:
                           F*ck – yeah!! OMG ☹
Please sign and date:
Sign: Signature - The W1nners' Club
Date: 26/01/2018

4.    For the employee only:

By ticking this box, I give my consent to my employer to disclose my personal information and details of the accident, which appear on this form to safety representatives to carry out the health and safety functions given to them by law.


Sign: Date: 26/01/2018

5.    For the employer:

Complete this box, if the accident is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR).
How was it reported?  We rang the address of the customer that Bill was working for because he wasn’t answering his mobile. Unfortunately this is what may have caused the accident as the customer was expecting a call from her daughter.
Sign: signature 2 - The W1nners' Club Date: 26/01/2018



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