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{"sheet":"（別紙第16）","index":0,"n_rows":45,"n_cols":34,"rows_kept":45,"cut":false,"hidden":false,"merged":[[23,22,24,22],[23,23,24,25],[12,0,12,3],[20,23,21,25],[20,6,21,8],[20,9,21,10],[20,11,21,12],[14,8,15,15],[16,16,16,33],[20,29,21,29],[20,33,21,33],[18,24,18,25],[19,0,27,1],[12,4,13,15],[20,26,21,27],[38,16,38,17],[25,2,27,9],[20,14,21,14],[22,2,24,5],[23,6,24,8],[35,17,35,21],[34,17,34,21],[23,16,24,17],[23,18,24,21],[19,2,21,5],[23,9,24,10],[20,18,21,21],[20,22,21,22],[23,26,24,27],[29,27,29,32],[41,0,41,33],[43,0,43,33],[31,33,32,33],[31,22,32,32],[31,18,32,18],[31,16,32,17],[31,14,32,15],[34,4,34,5],[31,2,31,3],[38,8,38,9],[36,17,36,21],[34,22,34,33],[35,22,35,33],[36,22,36,33],[38,31,38,32],[35,9,35,15],[3,11,3,22],[17,10,18,11],[17,12,18,13],[17,14,18,14],[2,0,2,33],[17,1,17,2],[18,1,18,2],[18,30,18,31],[18,27,18,28],[18,22,18,23],[16,0,16,12],[14,5,14,6],[15,5,15,6],[15,24,15,25],[15,22,15,23],[15,17,15,20],[44,0,44,33],[1,0,1,33],[20,17,21,17],[42,0,42,33],[30,0,36,1],[38,0,38,1],[32,2,32,3],[20,30,21,32],[23,30,24,32],[23,29,24,29],[23,33,24,33],[23,28,24,28],[23,11,24,12],[23,13,24,13],[23,14,24,15],[20,28,21,28],[5,0,5,12],[5,25,5,26],[15,30,15,31],[15,27,15,28],[8,1,10,13],[8,16,8,32],[7,1,7,13],[5,16,5,21],[10,16,10,19],[10,20,10,32],[13,22,13,23],[13,24,13,25],[13,27,13,28],[13,30,13,31]]}
["別紙第16"]
["国 家 公 務 員 災 害 補 償"]
["予　後　補　償　請　求　書"]
[]
[]
["(実施機関の長の官職氏名)",{"$nulls":15},"請求年月日",{"$nulls":8},"令和",null,null,"年",null,"月",null,"日"]
[{"$nulls":16},"請求者の住所"]
[{"$nulls":14},"殿"]
[null,"下記の予後補償を請求します。",{"$nulls":14},"　　　　　　　　　　　　　　　　　　　　　　　　"]
[]
[{"$nulls":16},"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",{"$nulls":10},"４（負傷又は発病年月日）"]
[{"$nulls":4},"□","非常勤",{"$nulls":20},"年",null,null,"月",null,null,"日"]
["５（請求日数）",{"$nulls":15},"６（治癒年月日）"]
[null,"令和",null,null,"年",null,"月",null,"日から",null,"のうち",null,null,null,"日"]
[null,"令和",null,null,"年",null,"月",null,"日まで",{"$nulls":17},"年",null,null,"月",null,null,"日"]
["７\n予後\n補償\n請求\n金額\nの計\n算　",null,"休業した日につ\nいて給与の全部\nを受けないとき",null,null,null,"（平均給与額）",{"$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"]
[]
[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},"）",{"$nulls":9},"（請求日数）"]
[{"$nulls":9},"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,"＝",{"$f":"X24*AC24","v":0},null,null,"円"]
[]
[null,null,"規則16－２第６条の規定により支給額が制限される場合"]
[]
[]
["８　予後補償請求金額"]
[{"$nulls":33},"円"]
["※\n９\n\n所属\n官署\n等の\n長の\n証明",null,"(治癒後勤務しなかった日数)",{"$nulls":16},"（休業した日に支払われた給与の総額）"]
[null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日から",null,"のうち",null,null,null,"日",{"$nulls":14},"円"]
[null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日まで"]
[null,null,"　上記のとおりであると認めます。"]
[{"$nulls":4},"令和",null,null,"年",null,"月",null,"日",{"$nulls":5},"所在地"]
[{"$nulls":9},"所属官署又は所属事務所の",{"$nulls":7},"名称"]
[{"$nulls":17},"長の官職氏名"]
["※受理",{"$nulls":7},"※決定",{"$nulls":7},"※支払",{"$nulls":7},"※決定金額"]
["令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日","令和",null,null,"年",null,"月",null,"日",{"$nulls":9},"円"]
[{"$nulls":24},"添付書類",{"$nulls":8},"枚"]
[]
["　注１　請求者は、※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　この請求書には、平均給与額算定書及び治癒の時期の決定に必要な医師の診断書を添付する"]
["　　　こと。ただし、この請求書の提出前に治癒の認定が行われている場合は、診断書を添付しなく"]
["　　　てもよい。"]