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Health and Safety Plan <br /> 1319 & 1327 South Madison Street, Stockton,CA <br /> 432770 <br /> IIPP FORM 3; Incident Investigation Report <br /> DEPARTMENT. <br /> Supervisor/Safety Coordinator Name: AEI Branch Location: <br /> Supervisor/Safety Coordinator Signature: Data: <br /> Person(s)Involved:(Include Titles) <br /> Location of Accidentlinjury: <br /> Time of Accident/Injury: Date of Accident/Injury: <br /> Task Being Performed when Aeddent Mmurred: <br /> NOTE: This form is intended to serve only as a local record of the investigation conducted within the <br /> department. Should an injury or illness occur, required forms must be submitted to Human Resources <br /> which will complete the required forms for Workers Compensation. Also, an IIPP Form 2, "Hazard <br /> Correction Report"must be completed in conjunction with any accident,injury or illness. <br /> Injury or Illness Specific Information: <br /> Parts of body affected: Was first aid rendered at tha time of the <br /> accident injury? Yes No <br /> If first ald was rendered,who rendered first ald?[Include full name and title] <br /> Was the employee advised to seek medical attention? Yes No <br /> If medical attention was advised, which medical facility/physician was the employee <br /> referred to?(Include address) <br /> Did a workplace condition,work practice or protective equipment contribute to the <br /> incident? <br /> Was the Code of Safe Practice violated? Yes No <br /> AEI Health h Safety,Injury A Minces PravcrrWn Program Page 124 <br /> Rerlsed 6/18/2013 <br />