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["別紙第55"]
[]
["国 家 公 務 員 災 害 補 償"]
[{"$nulls":8},"療　養",null,null,"の　現　状　報　告　書"]
[{"$nulls":7},"　","障　害"]
[]
["　（記入注意）",{"$nulls":28},"（表面）"]
["　１　療養、障害についてはいずれかを○で囲むこと。"]
["　２　５の欄の記入に当たっては、最近１年間について記入すること。"]
["　３　報告者は９の医師の証明欄には記入しないこと。"]
["　４　障害の現状を報告する場合には医師の証明は要しない。"]
["(実施機関の長の官職氏名)",{"$nulls":19},"令和",null,null,null,"年",null,"月",null,"日"]
[]
[{"$nulls":11},"殿"]
[]
["下記のとおり",null,null,"療養\n障害",null,"の現状を報告します。"]
[]
[{"$nulls":8},"報告者の住所"]
[]
[{"$nulls":8},"氏　　　　名"]
[]
[]
[]
[]
["１　負 傷 又 は 発 病 の 年 月 日",{"$nulls":8},"２　療 養 開 始 の 年 月 日",{"$nulls":10},"\n３\n","障害補償年金支給開始年月\n及び年金証書番号"]
[]
[null,null,"年",null,null,"月",null,null,"日",null,null,"年",{"$nulls":4},"月",null,null,"日",null,"年",null,"月",null,"第",null,null,"号"]
[]
["４　傷 病 名 又 は 障 害 等 級"]
[]
["５　傷病の経過又は障害の状況"]
[]
[]
[]
[]
[]
[]
["６　日常生活の概況"]
[]
[]
[]
[" ７\n 公的年\n 金の受\n 給関係",null,"年　　金　　の　　種　　類\n（障害等級第　　　　級）",{"$nulls":7},"年 金 の 年 額",{"$nulls":6},"年金証書の\n記号番号",null,null,null,"支給開始年月",null,null,null,"所 轄 年 金\n事 務 所 等"]
[]
[]
[]
[]
[]
["８　添付する書類その他の資料名"]
[]
[]
[]
[]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]

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[]
[]
["９　医師の証明",{"$nulls":28},"（裏面）"]
["（イ）　傷病又は障害の種類"]
[]
[]
[]
[]
[]
[]
["（ロ）　傷病の経過及び治療方法の概要"]
{"$rows_empty":7}
["（ハ）　傷病又は障害の現状"]
{"$rows_empty":8}
["（二）　今後の見込み"]
[]
[]
[]
[]
[]
[]
["　（報告者の氏名）"]
[]
[]
[{"$nulls":9},"については上記のとおりであると認めます。"]
[]
[{"$nulls":11},"令和",{"$nulls":6},"年",null,null,"月",null,null,"日"]
[]
[]
[{"$nulls":10},"所在地"]
[null,null,null,"病院又は診療所の",{"$nulls":6},"名　称"]
[{"$nulls":10},"医師氏名"]
[]
[]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]