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i <br /> ACCIDENT,INJURY& ILLNESS <br /> i INVESTIGATION FORM <br /> Person(s)Conducting Investigation: <br /> Title(s): <br /> Date of Accident/Injury/Illness: <br /> Names)of Affected Employee(s): (1) <br /> (2) (3) <br /> Nature of Accident/Injury/Illness: E <br /> I <br /> i <br /> Part(s)of Body Affected: <br /> What Workplace Condition,Work Practice,or Protective Equipment Contributed to the Incident: <br /> Was a Code of Safe Practice Violated? If so,Which One? <br /> { What Corrective Accounts will Prevent Another Occurrence? <br /> Was the Unsafe Condition,Practice,or Protective Equipment Problem Corrected Immediately? <br /> If No,What Has Been Done to Ensure Correction? <br /> Until Corrected,What Actions Have Been Takesâ–șto Prevent Recurrence? <br /> i <br /> Will the Inspection Checklist for the Area Require Modification to Prevent Recurrence? <br /> If so,What Will Be Added? <br /> I <br /> i <br /> i <br /> i <br /> Signature of Investigator Date <br /> Penson Responsible for <br /> Corrective Actions <br /> i <br /> I <br />