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ACCIDENT , INJURY , AND ILLNESS INVESTIGATION <br /> California Petroleum Equipment , Inc . <br /> P .O . Box 9364 <br /> Fresno , California 93792 <br /> ( 209 ) 276-1881 <br /> Date of Accident/Illness/Injury: <br /> Name( s ) of affected employees : <br /> Work Area/Job Safety Class of Affected Employee( s ): <br /> Nature of Accident/Injury/Illness : <br /> Part( s ) of Body Affected: <br /> What Workplace Condition , Work Practice , or Protective Equipment <br /> Contributed to the Incident : <br /> Was a Code of Safe Practice Violated: <br /> If So , Which One : <br /> What Corrective Actions Will Prevent Another Occurence: <br /> Will an Additional Code of Safe Practice Be Needed: <br /> If So , State It : <br /> Was the Unsafe Condition , Practice , or Protective Equipment Problem <br /> Corrected Immediately: <br /> If Not , What Has Been Done to Assure Correction : _ <br /> Until Corrected , What Actions Have Been Taken to Prevent Recurrences <br /> in the Interim: <br />