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..i <br /> JOB-SITE ACCIDENT/INCIDENT INVESTIGATION REPORT <br /> Date of Incident/Accident: I Location: <br /> Check all that apply: In' Illness Fatal Vehicle Property Damage <br /> In'ured's Name: <br /> Choose One: ( )Nor-Cal ( )Contractor ( )Public <br /> Employee <br /> Birthdate: Male Female SSN#: <br /> Address City State/Zip <br /> Telephone(incl. area code): ( ) On Duty ( ) Off Duty Date Accident Reported: <br /> Activity at time of incident/injury/illness <br /> Nature of injury/illness/accident/incident: <br /> How did accident/incident occur? <br /> Describe Property Damaged: <br /> What can be done to prevent recurrence of the accident/incident? <br /> What has been done to prevent recurrence of the accident/incident? <br /> Supervisor's Signature Date <br /> Reviewer's Signature Date <br />