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PF <br /> O <br /> PF"" ' <br /> G <br /> ontractors License #692238 n0 ,��� <br /> (916) 878-6834 • Fax(916)878x436 �' P.O. Box 7169 <br /> RUCTIo Auburn,California 95604 <br /> INJURY/ILLNESS INVESTIGATION FORM <br /> Date: <br /> Jobsite: <br /> Date of Reported Injury/Illness Injury: <br /> Description of Incident: <br /> Name of Employes(s) Involved: <br /> Cause(s) of Incident, If Known: <br /> Means of Preventing Reoccurrence, If Known: <br /> 1 <br /> i <br /> Interim Measures Required to Prevent Reoccurrence: <br /> i <br /> i <br /> Modification of Code of Safe Practices Required: <br /> investigation Completed by: <br /> Date of Review and Approval by Responsible Person: <br /> Date of Implementation of Interim Corrective Actions : <br /> Date of implementation of Permanent Corrective Actions: <br /> Signature of Person Responsible for Corrections (upon completion) <br /> Date <br />