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["別紙第２"]
["国 家 公 務 員 災 害 補 償"]
[{"$nulls":11},"休業補償請求書"]
[{"$nulls":11},"休業援護金支給申請書"]
[{"$nulls":25},"請求（申請）回数",{"$nulls":4},"第",null,null,"回"]
["(実施機関の長の官職氏名)",{"$nulls":15},"請求(申請)年月日",{"$nulls":8},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":14},"殿",null,"請求(申請)者の住所"]
[null,"下記の",null,"休業補償を請求",{"$nulls":7},"します。",{"$nulls":4},"　　　　　　　　　　　　　　　　　　　　　　　　"]
[null,null,null,"休業援護金の支給を申請",{"$nulls":12},"氏　名"]
[]
["１（所属部局）",{"$nulls":15},"２（氏　名）"]
[{"$nulls":26},"年",null,null,"月",null,null,"日生"]
["３（官　職）",null,null,null,"□","常　勤",{"$nulls":10},"４　 負 傷 又 は"]
[{"$nulls":4},"□","非常勤",{"$nulls":11}," 発病年月日",{"$nulls":8},"年",null,null,"月",null,null,"日"]
["５　　厚生年金保険",{"$nulls":5},"□",{"$nulls":4},"の被保険者である。",{"$nulls":4},"被保険者証書等の記号番号",{"$nulls":8},"所轄年金事務所等"]
["　　　法等の適用",{"$nulls":5},"□","被保険者でない。"]
["６（請求（申請）日数）",{"$nulls":15},"休　　業　　補　　償",{"$nulls":8},"休　業　援　護　金"]
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[null,"全部休業","休業した日につ\nいて給与の全部\nを受けないとき",null,null,null,"（平均給与額）",{"$nulls":20},"（請求日数）"]
[{"$nulls":9},"円 ×",null,"60\n100",null,null,"＝",null,null,null,{"$f":"ROUNDDOWN(G21*0.6,0)","v":0},null,null,null,"円",{"$f":"S21","v":0},null,null,"円×",null,null,"＝",{"$f":"X21*AC21","v":0},null,null,"円"]
["７"]
[null,null,"休業した日につ\nいて給与の一部\nを受けないとき",null,null,null,"（平均給与額）",{"$nulls":5},"（",{"$nulls":4},"）",{"$nulls":9},"（請求日数）"]
["休",{"$nulls":8},"円 ×",null,"60\n100",null,"－",null,null,"円 ＝",null,{"$f":"ROUNDDOWN((G24*0.6)-O24,0)","v":0},null,null,null,"円",{"$f":"S24","v":0},null,null,"円×",null,null,"＝",{"$f":"X24*AC24","v":0},null,null,"円"]
[]
["業","一部休業",null,"（平均給与額）",{"$nulls":5},"（",null,null,null,"）",{"$nulls":13},"（請求日数）"]
[null,null,"（",{"$nulls":5},"円 －",{"$nulls":4},"円）×",null,"60\n100",null,"＝",{"$f":"ROUNDDOWN((D27-K27)*0.6,0)","v":0},null,null,null,"円",{"$f":"S27","v":0},null,null,"円×",null,null,"＝",{"$f":"X27*AC27","v":0},null,null,"円"]
["補"]
[null," 補償法第14条又は昭和41\n 年改正法附則第８条の規\n 定により支給額が制限又\n は調整される場合"]
["償"]
[]
[]
[null,"休業補償請求金額",{"$nulls":31},"円"]
["８休業援護金","（休業援護金支給申請額の計算）"]
[]
[]
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[null,"（休業援護金支給申請額）",{"$nulls":31},"円"]
[null,"(傷病名)",{"$nulls":14},"(現在の状態)"]
["※",{"$nulls":16},"令和",null,null,null,"年",null,null,"月",null,null,"日"]
["９",{"$nulls":16},"□","治癒",null,"□","死亡",null,"□","転医",null,"□","中止",null,"□","継続中"]
[null,"　請求日数のうち療養のため勤務することが",{"$nulls":14},"(勤務することができなかったと認められる理由)"]
["医","　できなかったと認められる日数"]
["師","令和",null,null,"年",null,"月",null,"日から",null,"のうち",null,null,null,"日"]
["の","令和",null,null,"年",null,"月",null,"日まで"]
["証","　上記のとおりであると認めます。"]
["明",null,"令和",null,null,"年",null,"月",null,"日",{"$nulls":7},"所在地"]
[{"$nulls":11},"病院又は診療所の",{"$nulls":5},"名称"]
[{"$nulls":17},"医師氏名"]
["※\n10\n\n所属\n官署\n等の\n長の\n証明",null,"(療養のため勤務せず、かつ、給与を受けなかった日数)",{"$nulls":19},"（休業した日に支払われた給与の総額）"]
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[null,null,"　上記のとおりであると認めます。"]
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[{"$nulls":9},"所属官署又は所属事務所の",{"$nulls":7},"名称"]
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["※受理",{"$nulls":7},"※決定",{"$nulls":7},"※決定金額",{"$nulls":9},"添付書類"]
["令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日",{"$nulls":9},"円",{"$nulls":7},"枚"]
["　補償法第32条の2の規定に",{"$nulls":6},"※","□","200円",null,"□","免　除",null,"※支払",{"$nulls":7},"※支払\n　金額",null,"休業補償",{"$nulls":8},"円"]
["　基づく一部負担金の控除",{"$nulls":7},"□","100円",null,"□","控除済",null,"令和",null,null,"年",null,"月",null,"日",null,null,"休業援護金",{"$nulls":8},"円"]
["　注１　請求(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　「６　(請求(申請)日数)」の欄中、全部休業に係る項目には、一日の全部にわたって休業し、給与の全部又は一部を受けなかった\n　　　日の日数を、一部休業に係る項目には、正規の勤務時間の一部を休業したために、受けた給与の額が平均給与額以下であった日の\n　　　日数を記入すること。"]
["　　３　この請求(申請)書には、平均給与額算定書を添付すること。ただし、第２回目以降の請求において平均給与額に変更がない場合\n　　　は、平均給与額算定書を添付しなくてよい。　　　　　"]
["　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　"]