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{"sheet":"申込書","index":0,"n_rows":69,"n_cols":37,"rows_kept":69,"cut":false,"hidden":false,"merged":[[37,0,38,5],[37,6,38,23],[45,0,50,5],[45,15,47,21],[48,15,50,21],[39,6,40,23],[45,9,50,12],[45,6,50,8],[49,13,50,14],[45,13,46,14],[47,13,48,14],[39,0,40,5],[43,0,44,8],[37,38,38,49],[39,38,40,49],[35,36,36,37],[37,36,38,37],[39,36,40,37],[0,0,1,49],[5,41,6,49],[5,36,6,40],[35,24,36,35],[27,6,29,28],[18,35,20,49],[35,0,36,5],[24,0,26,5],[18,29,20,34],[27,29,29,34],[18,6,20,28],[18,0,20,5],[31,0,32,7],[33,24,34,49],[33,0,34,5],[35,38,36,49],[24,35,26,49],[27,35,29,49],[21,29,23,34],[24,29,26,34],[2,0,3,49],[37,24,38,35],[39,24,40,35],[7,1,8,15],[9,1,10,15],[9,16,10,18],[33,6,34,23],[35,6,36,23],[21,0,23,5],[21,6,23,28],[25,6,26,28],[27,0,29,5],[14,0,15,7],[16,0,17,7],[24,6,24,10],[24,11,24,28],[21,35,23,49],[68,2,73,51],[45,27,47,28],[48,27,50,28],[45,22,47,26],[48,22,50,26],[54,2,65,49],[52,1,53,19],[66,1,67,19],[45,29,50,49]]}
["東京都報道事業健康保険組合"]
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["2025年度　インフルエンザワクチン予防接種申込書（出張予防接種用）"]
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[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申込日"]
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[null,"公益財団法人　　結核予防会"]
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[null,"総合健診センター出張健診課",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"宛"]
[]
[]
[null,"以下のとおり、出張によるインフルエンザワクチン予防接種を申込みいたします。"]
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["【事業所記入欄】",null,null,null,null,null,null,null,null,null,null,"＝書込み可能セル"]
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["１．事業所情報"]
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["事 業 所 名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当部署名"]
[]
[]
["住　　　所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"事業所記号"]
[]
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["担 当 者 名",null,null,null,null,null,"(フリガナ)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電 話 番 号"]
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["e-mail\nアドレス",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"F A X番号"]
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[]
[]
["２．接種希望日時"]
[]
[null,null,null,null,null,null,"年月日（曜日）※",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"希望接種時間帯　※1."]
[]
["第1希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"～"]
[]
["第2希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"～"]
[]
["第3希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"～"]
[]
["※",null,"土日・祝日は除きます。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※1.",null,"12：00～13：00の時間帯は除きます。"]
[]
["３．接種申込人数"]
[]
["申込人数\n（名簿人数）",null,null,null,null,null,"合計",null,null,{"$f":"W46+W49","v":0},null,null,null,null,null,"被保険者本人",null,null,null,null,null,null,null,null,null,null,null,"人",null,"●被保険者本人負担金　　￥300(税込)\n\n●被保険者外　負担金　　￥4,000(税込) ※2"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"人"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者外",null,null,null,null,null,null,null,null,null,null,null,"人"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※2.",null,"被保険者外の接種料金は実費分をご負担いただきます。"]
[null,"■■■お申込みの際の注意事項■■■"]
[]
[null,null,"①　出張による予防接種は１００名様を目途にお伺いいたします。\n②　接種希望日の１か月前までにお申し込みください。尚、日程調整の都合上、希望接種日以外でご相談させて\n　　いただく場合がございます。\n③　予防接種時間は、お申込み人数によってご相談させていただきます。\n④　負担金は予防接種後に会社様へ一括請求いたします。尚、予防接種当日の接種料金の金銭授受は出来ません。\n⑤　個別（個人）の領収証の発行は致し兼ねますことをご了承ください。\n⑥　会議室等の独立した予防接種会場を必ずご用意ください。\n⑦　予防接種用、診察用等のテーブルおよび椅子をご用意ください。設営は当方で行います。"]
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[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"■■■予防接種時の注意事項■■■"]
[]
[null,null,"①　予診票は裏面の注意事項を熟読し事前に記入し接種会場へお持ち下さい。尚、体温は接種直前に測定します。\n②　予防接種前の受付の際には、必ず「資格確認のできるもの」をご提示ください。\n　　・マイナ保険証と資格情報のお知らせ　・マイナポータルの資格確認画面　・資格確認書または被保険者証\n③　１６歳未満の方の接種はお受けいたしません。（小児科医の判断が必要な為）\n④　当日の予診結果により、予防接種をお断りする場合がございます。（既往歴、発熱等）"]

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["2025年度　インフルエンザワクチン予防接種申込者名簿（出張予防接種用）"]
["(必要に応じてコピーしてお使い下さい）※番号順にて記載をお願い致します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＝書込み可能セル"]
["事業所名",null,null,null,null,{"$f":"申込書!G19","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記　号",null,null,null,null,{"$f":"申込書!AJ22","v":0}]
["接種日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"健保名",null,null,null,null,"東京都報道事業健康保険組合"]
["№",null,"保険証番号",null,null,null,null,"漢字氏名",null,null,null,null,null,null,null,null,null,null,"ｶﾅ氏名（半角）",null,null,null,null,null,null,null,null,null,null,"性別",null,"続柄",null,"生年月日",null,null,null,null,null,null,null,null,"備考"]
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