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["別紙第22"]
[]
["福　祉　事　業　申　請　書"]
[]
["（実施機関の長の官職氏名）",{"$nulls":11},"申 請 年 月 日",{"$nulls":5},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":12},"（申請者の住所）"]
[{"$nulls":11},"殿","（氏　　　　名）"]
["　下記の福祉事業を受けたいので申請します。",{"$nulls":11},"（生年月日）",{"$nulls":8},"年",null,"月",null,"日生"]
["１（所属部局）",{"$nulls":11},"３","（傷　病　名）"]
[{"$nulls":12},"４","（負傷又は"]
[{"$nulls":13},"　発病年月日）",{"$nulls":7},"年",null,"月",null,"日"]
["２（官　職）",{"$nulls":11},"５","（傷病等級該\n　当又は治癒の\n　年月日）"]
[{"$nulls":21},"年",null,"月",null,"日"]
[null,null,"□","常　勤"]
[null,null,"□","非常勤",{"$nulls":8},"６","（補償の種類）"]
[{"$nulls":12},"□","傷病補償年金（傷病等級",{"$nulls":5},"第",null," 級第",null,null,"号）"]
[{"$nulls":12},"□","障 害 補 償 （障害等級",{"$nulls":5},"第",null," 級第",null,null,"号）"]
["７　福　祉　事　業　の　種　類",{"$nulls":7},"□","外科後処置",null,null,"□"," 補装具  （",null,null,"□","支給","□","再支給",null,"□","修理 ）",null,"□","リハビリ"]
[{"$nulls":8},"  テーション",null,null,"□","アフターケア",null,null,null,"□","ホームヘルプサービス(",{"$nulls":4},"□","旅行費）"]
["８　内　 容　 及　 び　 理　 由"]
[]
["９　希　 望　 す　 る　 期　 間 　",{"$nulls":7},"令和",null,null,"年",null,"月",null,"日","から",{"$nulls":5},"日間"]
[{"$nulls":8},"令和",null,null,"年",null,"月",null,"日","まで"]
["10　希望する施設､事業者等の名称\n　　及びその所在地"]
[]
["※",{"$nulls":7},"※",{"$nulls":6},"承　認",null,null,"※"]
["令和",null,"年",null,"月",null,"日","受理","令和",null,"年",null,"月",null,"日",null,null,"決定","令和",null,"年",null,"月",null,"日","通知"]
[{"$nulls":15},"不承認"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　",{"$nulls":17},"添付書類",{"$nulls":6},"枚"]
[]
["　注　１　申請者は、※印の欄には記入しないこと。該当する□にレ印を記入すること。"]
["　　　２　「８　内容及び理由」の欄には、当該福祉事業に要する金額を予定できる場合にその予定額も記入すること。"]
["　　　３　「９　希望する期間」の欄には、リハビリテ－ション又はホ－ムヘルプサ－ビスを受けようとする場合に記"]
["　　　　入すること。"]
["　　　４　外科後処置、リハビリテ－ション又はアフタ－ケアを申請する場合には、人事院規則16－４（補償及び福"]
["　　　　祉事業の実施）第21条第1項の定めるところにより、必要な書類を添付すること。"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]
[]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 　"]