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["別記第１号様式（第５条関係）",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,null,null,null,null,null,"令和",null,null,null,null,"年",null,null,null,"月",null,null,null,null,"日",null,null,null,null,null,null,null,null,null,null,"⇒記入日を記入"]
[]
[null,null,null,null,null,null,"訪問介護　外 出 介 助　サービス事業利用 申 請 書 兼 派遣指示書"]
[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,null,"（","　要支援",null,null,null,null,null,null,null,null,null," 要介護",null,null,null,null,null,null,null,"）",null,null,false,false,null,null,null,null,null,null,"⇒該当の認定区分に☑をいれ、介護度（数字）を記入"]
["渋谷区長　殿"]
[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,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒申請者についての情報を記入"]
["訪問介護事業者　",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,"氏名"]
[null,"サービス提供事業者名",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,null,"被保険者番号"]
[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,"住　　　所",null,null,null,null,null,null,null,"渋谷区",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK11=TRUE,AS11+1867,)","v":0},{"$f":"IF(BL11=TRUE,AS11+1911,)","v":0},{"$f":"IF(BM11=TRUE,AS11+1925,0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK11=TRUE,BK9,IF(BL11=TRUE,BL9,BM9))","v":0}]
[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,"生年月日",null,null,null,null,null,null,"明",null,"大",null,"昭",null,null,null,"年",null,null,"月",null,null,"日","年齢（",null,null,{"$f":"IF(AY11=\"\",\"\",DATEDIF(BK10&\"年\"&AV11&\"月\"&AY11&\"日\",TODAY(),\"Y\"))","v":""},null,null,"歳）",null,null,false,false,false,null,null,null,null,null,"⇒年号に☑を入れ、生年月日を入力すると年齢は自動で計算"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿",null,null,null,null,null,null,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,false,false]
[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,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,false,false]
[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,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,"⇒押印は不要となりました。"]
[]
["地域包括支援センター・ケアマネジャー記入欄"]
["派遣開始日",null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
["派遣希望回数及び時間数　（御利用時間は午前８時から午後７時までです。）"]
["サービス\n内　容No.",null,null,null,null,"派遣希望回数",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,"派遣希望時間数"]
[null,null,null,null,null,"単発利用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"継続利用",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,null,null,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false,false,false,false,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[]
["該当する□全てにレ印をつけてください。"]
["①　他に利用している区独自のサービス",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,null,null,null,null,null,null,null,null,"④　サービスが必要な理由"]
[null,"生活援助サービス",null,null,null,null,null,null,null,null,null,null,"　高齢者世帯援助サービス",null,null,null,null,null,null,null,null,null,null,null,null,"　外出介助サービス",null,null,null,null,null,null,null,null,null,null,null,"　　（利用者の状態、期待される効果等)"]
["②　サービス内容"]
[null," １　院内付添のみ（往復は介護保険又は総合事業を利用。）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,"病院名(",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,null,null,null,null,null,"）"]
[]
[null," ２ 通院介助　（院内付添＋往復も区独自を利用）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,"タクシー利用：",null,null,null,null,null,null,null,null,"有",null,null,null,"無",null,null,"→　無の場合（",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,null,null,null,null,false,false]
[null,"病院名(",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,null,null,null,null,null,"）"]
[]
[null," ３　散歩、近隣施設等への外出介助",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,"外出先(",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,"）"]
[]
["③　申請理由"]
[null,null,"介護保険・総合事業が使えない内容のため",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,"利用限度を超えているため",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"地域包括支援センター",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担　当："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先："]

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["別記第１号様式（第５条関係）",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,null,null,null,null,null,"令和",null,null,null,null,"年",null,null,null,"月",null,null,null,null,"日",null,null,null,null,null,"⇒記入日を記入"]
[]
[null,null,null,null,null,null,"訪問介護　外 出 介 助　サービス事業利用 申 請 書 兼 派遣指示書"]
[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,null,"（","　要支援",null,null,null,null,null,null,null,null,null," 要介護",null,null,null,null,null,null,null,"）",null,null,false,false,null,"⇒該当の認定区分に☑をいれ、介護度（数字）を記入"]
["渋谷区長　殿"]
[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,"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,null,null,null,null,null,null,null,null,null,null,null,"⇒申請者についての情報を記入"]
["訪問介護事業者　",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,"氏名"]
[null,"サービス提供事業者名",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,null,"被保険者番号"]
[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,"住　　　所",null,null,null,null,null,null,null,"渋谷区",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK11=TRUE,AS11+1867,)","v":0},{"$f":"IF(BL11=TRUE,AS11+1911,)","v":0},{"$f":"IF(BM11=TRUE,AS11+1925,0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK11=TRUE,BK9,IF(BL11=TRUE,BL9,BM9))","v":0}]
[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,"生年月日",null,null,null,null,null,null,"明",null,"大",null,"昭",null,null,null,"年",null,null,"月",null,null,"日","年齢（",null,null,{"$f":"IF(AY11=\"\",\"\",DATEDIF(BK10&\"年\"&AV11&\"月\"&AY11&\"日\",TODAY(),\"Y\"))","v":""},null,null,"歳）",null,null,false,false,false,"⇒年号に☑を入れ、生年月日を入力すると年齢は自動で計算"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿",null,null,null,null,null,null,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,false,false]
[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,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,false,false]
[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,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,"⇒押印は不要となりました。"]
[]
["地域包括支援センター・ケアマネジャー記入欄"]
["派遣開始日",null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
["派遣希望回数及び時間数　（御利用時間は午前８時から午後７時までです。）"]
["サービス\n内　容No.",null,null,null,null,"派遣希望回数",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,"派遣希望時間数"]
[null,null,null,null,null,"単発利用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"継続利用"]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[]
["該当する□全てにレ印をつけてください。"]
["①　他に利用している区独自のサービス",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,null,null,null,null,null,null,null,null,"④　サービスが必要な理由"]
[null,"生活援助サービス",null,null,null,null,null,null,null,null,null,null,"　高齢者世帯援助サービス",null,null,null,null,null,null,null,null,null,null,null,null,"　外出介助サービス",null,null,null,null,null,null,null,null,null,null,null,"　　（利用者の状態、期待される効果等)"]
["②　サービス内容"]
[null," １　院内付添のみ（往復は介護保険又は総合事業を利用。）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,"病院名(",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,null,null,null,null,null,"）"]
[]
[null," ２ 通院介助　（院内付添＋往復も区独自を利用）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,"タクシー利用：",null,null,null,null,null,null,null,null,"有",null,null,null,"無",null,null,"→　無の場合（",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,null,null,null,null,false,false]
[null,"病院名(",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,null,null,null,null,null,"）"]
[]
[null," ３　散歩、近隣施設等への外出介助",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,"外出先(",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,"）"]
[]
["③　申請理由"]
[null,null,"介護保険・総合事業が使えない内容のため",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,"利用限度を超えているため",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"地域包括支援センター",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担　当："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先："]

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["別記第１号様式（第５条関係）",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,null,null,null,null,null,"令和",null,null,8,null,"年",null,3,null,"月",null,1,null,null,"日",null,null,null,null,null,null,"⇒記入日を記入"]
[]
[null,null,null,null,null,null,"訪問介護　外 出 介 助　サービス事業利用 申 請 書 兼 派遣指示書"]
[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,null,"（","　要支援",null,null,null,null,null,null,null,null,null," 要介護",null,null,null,2,null,null,null,"）",null,null,false,true,null,null,"⇒該当の認定区分に☑をいれ、介護度（数字）を記入"]
["渋谷区長　殿"]
[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,"フリガナ",null,null,null,null,null,null,null,null,null,"シブヤ　タロウ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒申請者についての情報を記入"]
["訪問介護事業者　",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,"氏名",null,null,null,null,null,null,null,null,null,"渋谷　太郎"]
[null,"サービス提供事業者名",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,null,"被保険者番号",null,null,null,null,null,null,null,null,null,"123456"]
[null,"ホームヘルプ△△△\n渋谷○○サービス",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,null,"住　　　所",null,null,null,null,null,null,null,"渋谷区",null,null,null,"宇田川町１－１",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK11=TRUE,AS11+1867,)","v":0},{"$f":"IF(BL11=TRUE,AS11+1911,)","v":0},{"$f":"IF(BM11=TRUE,AS11+1925,0)","v":1932}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,"03-3463-1211",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK11=TRUE,BK9,IF(BL11=TRUE,BL9,BM9))","v":1932}]
[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,"生年月日",null,null,null,null,null,null,"明",null,"大",null,"昭",null,7,null,"年",10,null,"月",1,null,"日","年齢（",null,null,{"$f":"IF(AY11=\"\",\"\",DATEDIF(BK10&\"年\"&AV11&\"月\"&AY11&\"日\",TODAY(),\"Y\"))","v":93},null,null,"歳）",null,null,false,false,true,null,"⇒年号に☑を入れ、生年月日を入力すると年齢は自動で計算"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"殿",null,null,null,null,null,null,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,false,true]
[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,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,false,true]
[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,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,"⇒押印は不要となりました。"]
[]
["地域包括支援センター・ケアマネジャー記入欄"]
["派遣開始日",null,null,null,null,null,null,"令和",null,null,null,null,8,null,null,null,"年",null,3,null,"月",14,null,null,"日"]
["派遣希望回数及び時間数　（御利用時間は午前８時から午後７時までです。）"]
["サービス\n内　容No.",null,null,null,null,"派遣希望回数",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,"派遣希望時間数"]
[null,null,null,null,null,"単発利用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"継続利用"]
["2,3",null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",5,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,true]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[null,null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",null,null,"回 利用",null,null,null,"  30分",null,null,null," １時間",null,null,null,"１時間30分",null,null,null,null,"2時間 ",null,null,null,"2時間30分",null,null,null,null,null,null,false,false]
[]
["該当する□全てにレ印をつけてください。"]
["①　他に利用している区独自のサービス",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,null,null,null,null,null,null,null,null,"④　サービスが必要な理由"]
[null,"生活援助サービス",null,null,null,null,null,null,null,null,null,null,"　高齢者世帯援助サービス",null,null,null,null,null,null,null,null,null,null,null,null,"　外出介助サービス",null,null,null,null,null,null,null,null,null,null,null,"　　（利用者の状態、期待される効果等)"]
["②　サービス内容"]
[null," １　院内付添のみ（往復は介護保険又は総合事業を利用。）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,"病院名(",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,null,null,null,null,null,"）"]
[]
[null," ２ 通院介助　（院内付添＋往復も区独自を利用）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,true]
[null,"タクシー利用：",null,null,null,null,null,null,null,null,"有",null,null,null,"無",null,null,"→　無の場合（",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,null,null,null,null,true,false]
[null,"病院名(",null,null,null,null,"○○○病院",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," ３　散歩、近隣施設等への外出介助",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,true]
[null,"外出先(",null,null,null,null,"渋谷駅周辺を散歩",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,"）"]
[]
["③　申請理由"]
[null,null,"介護保険・総合事業が使えない内容のため",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,true]
[null,null,"利用限度を超えているため",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,"○○ケアプランサービス",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"地域包括支援センター",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担　当：",null,null,null,null,"福祉　八公"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先：",null,null,null,null,"03-3463-xxxx"]