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Mobile phone in tarmac - The W1nners' Club

1.    About the person who had the accident:

Name: Bill Jones
Address: 23 Sycamore Lane, Barnsley, South Yorkshire
Postcode: S71 2JH
Occupation: Road Construction Operative

2.    About you the person filling in this record:

Complete if you did not have the accident:
Name: Dave Smith
Address: 67 Stocks Street, Barnsley, South Yorkshire
Postcode: S75 6YJ
Occupation: Road Construction Operative

3.    About the accident:

Say when it happened:
Date: 13/10/2017 Time: 10:00am
Say where it happened (which room or place):
Old Sheffield Rd, Barnsley
Say how it happened (include the cause if you can):
I was driving the road roller and Bill was up in front of me laying tarmac with a shovel. Usually he he’ll lay a bit down and then get out of the way as I drive up behind him in the roller. On this occasion Bill received a phone call on his mobile and got so engaged in the conversation that he forgot to move out of the way.
Say if the person who had the accident suffered any injury:
It’s hard to say as there wasn’t much left of him apart from his mobile phone (see picture attached).
Please sign and date:
Sign: signature 2 - The W1nners' Club
Date: 13/10/2017

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:

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 called Bill on his mobile to ask him if he’d come into work over the weekend. He started swearing saying that he had bought tickets for the Barnsley game before the phone went dead all of a sudden….…….
Sign: signature 1 - The W1nners' Club Date: 13/10/2017


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