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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,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒記入日を記入"]
[null,null,null,null,null,"訪問介護",null,null,null,null,null,null,null,null,null,null,"生活援助",null,null,null,null,null,null,null,null,null,null,null,null,"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,false,false,null,null,null,null,null,null,"⇒生活援助又は高齢者世帯援助に☑をいれる。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"高齢者世帯援助",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,"生活援助か世帯援助を選択すると、太字になり、□で囲う"]
["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,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,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"]
[null,null,null,null,null,null,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"]
["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,"氏名",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,null,null,null,null,null,"⇒申請者についての情報を記入"]
[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,"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,"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,null,{"$f":"IF(BK12=TRUE,AR12+1867,\"\")","v":""},{"$f":"IF(BL12=TRUE,AR12+1911,\"\")","v":""},{"$f":"IF(BM12=TRUE,AR12+1925,0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK12=TRUE,BK10,IF(BL12=TRUE,BL10,BM10))","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,"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(AX12=\"\",\"\",DATEDIF(BK11&\"年\"&AU12&\"月\"&AX12&\"日\",TODAY(),\"Y\"))","v":""},null,null,"歳）",null,null,null,false,false,false,null,null,null,null,null,"⇒年号に☑をいれ、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,"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,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,"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,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,"\n⇒押印は不要となりました。"]
[]
["援助が必要な同居高齢者　（高齢者世帯援助サービスを申請する場合に記入）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【援助が必要な同居高齢者】"]
["氏　名",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,"生年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護認定",null,null,null,null,null,null,null,null,"チェックリスト",null,null,null,null,null,null,null,null,"続　柄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒高齢者世帯援助の申請時のみ記入"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,"未申請",null,null,null,"自立",null,null,null,null,"未実施",null,null,null,"非該当",null,null,null,null,null,null,null,null,null,null,false,false,false,false,null,null,null,null,"　同居高齢者についての情報を記入（※必ず基本チェックリストを実施の上、ご提出ください。）"]
[]
["地域包括支援センター・ケアマネジャー記入欄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"高齢者世帯援助を選択するとタイトルが黄色になる。しかし、項目を埋めると"]
["派遣開始日",null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（生年月日のみ日にち、チェックボックスはどちらか選択）すると色付け無しに戻る"]
["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,"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,"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,null,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,false,false,false,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,false,false,false,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,false,false,false,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,false,false,false,false,false,false,false]
[]
[]
["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,"外出介助サービス　",null,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,null,"１　食事の準備、調理"]
[null,null,"２　洗濯、衣類の整理、補修"]
[null,null,"３　居室等の掃除"]
[null,null,"４　その他　",null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")",null,null,null,null,null,null,null,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]
[]
["③　申請理由"]
[null,null," 同居家族等の存在により介護保険・総合事業の生活援助の全部",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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," 又は一部が受けられないため",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," 同居家族等が援助することができないため",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," 同居家族等の負担軽減が必要なため"]
[]
[]
[]
[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,"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,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒記入日を記入"]
[null,null,null,null,null,"訪問介護",null,null,null,null,null,null,null,null,null,null,"生活援助",null,null,null,null,null,null,null,null,null,null,null,null,"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,false,false,null,null,null,null,null,null,"⇒生活援助又は高齢者世帯援助に☑をいれる。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"高齢者世帯援助",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,"生活援助か世帯援助を選択すると、太字になり、□で囲う"]
["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,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,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"]
[null,null,null,null,null,null,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"]
["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,"氏名",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,null,null,null,null,null,"⇒申請者についての情報を記入"]
[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,"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,"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,null,{"$f":"IF(BK12=TRUE,AR12+1867,\"\")","v":""},{"$f":"IF(BL12=TRUE,AR12+1911,\"\")","v":""},{"$f":"IF(BM12=TRUE,AR12+1925,0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK12=TRUE,BK10,IF(BL12=TRUE,BL10,BM10))","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,"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(AX12=\"\",\"\",DATEDIF(BK11&\"年\"&AU12&\"月\"&AX12&\"日\",TODAY(),\"Y\"))","v":""},null,null,"歳）",null,null,null,false,false,false,null,null,null,null,null,"⇒年号に☑をいれ、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,"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,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,"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,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,"\n⇒押印は不要となりました。"]
[]
["援助が必要な同居高齢者　（高齢者世帯援助サービスを申請する場合に記入）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【援助が必要な同居高齢者】"]
["氏　名",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,"生年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護認定",null,null,null,null,null,null,null,null,"チェックリスト",null,null,null,null,null,null,null,null,"続　柄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒高齢者世帯援助の申請時のみ記入"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,"未申請",null,null,null,"自立",null,null,null,null,"未実施",null,null,null,"非該当",null,null,null,null,null,null,null,null,null,null,false,false,false,false,null,null,null,null,"　同居高齢者についての情報を記入（※必ず基本チェックリストを実施の上、ご提出ください。）"]
[]
["地域包括支援センター・ケアマネジャー記入欄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"高齢者世帯援助を選択するとタイトルが黄色になる。しかし、項目を埋めると"]
["派遣開始日",null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（生年月日のみ日にち、チェックボックスはどちらか選択）すると色付け無しに戻る"]
["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,"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,"継続利用"]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,false,false,false,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,false,false,false,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,false,false,false,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,false,false,false,false,false,false,false]
[]
[]
["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,"外出介助サービス　",null,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,null,"１　食事の準備、調理"]
[null,null,"２　洗濯、衣類の整理、補修"]
[null,null,"３　居室等の掃除"]
[null,null,"４　その他　",null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")",null,null,null,null,null,null,null,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]
[]
["③　申請理由"]
[null,null," 同居家族等の存在により介護保険・総合事業の生活援助の全部",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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," 又は一部が受けられないため",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," 同居家族等が援助することができないため",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," 同居家族等の負担軽減が必要なため"]
[]
[]
[]
[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,"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,"令和",null,null,8,null,"年",null,3,null,"月",null,1,null,null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒記入日を記入"]
[null,null,null,null,null,"訪問介護",null,null,null,null,null,null,null,null,null,null,"生活援助",null,null,null,null,null,null,null,null,null,null,null,null,"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,false,true,null,null,null,null,null,null,"⇒生活援助又は高齢者世帯援助に☑をいれる。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"高齢者世帯援助",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,"生活援助か世帯援助を選択すると、太字になり、□で囲う"]
["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,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,null,false,true,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"]
[null,null,null,null,null,null,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"]
["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,"氏名",null,null,null,null,null,null,null,null,null,"渋谷　太郎",null,null,null,null,null,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"]
[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,"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,"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,null,{"$f":"IF(BK12=TRUE,AR12+1867,\"\")","v":""},{"$f":"IF(BL12=TRUE,AR12+1911,\"\")","v":""},{"$f":"IF(BM12=TRUE,AR12+1925,0)","v":1932}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,"03-3463-1211",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BK12=TRUE,BK10,IF(BL12=TRUE,BL10,BM10))","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,"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(AX12=\"\",\"\",DATEDIF(BK11&\"年\"&AU12&\"月\"&AX12&\"日\",TODAY(),\"Y\"))","v":93},null,null,"歳）",null,null,null,false,false,true,null,null,null,null,null,"⇒年号に☑をいれ、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,"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,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,"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,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,null,null,null,null,"\n⇒押印は不要となりました。"]
[]
["援助が必要な同居高齢者　（高齢者世帯援助サービスを申請する場合に記入）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【援助が必要な同居高齢者】"]
["氏　名",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,"生年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"要介護認定",null,null,null,null,null,null,null,null,"チェックリスト",null,null,null,null,null,null,null,null,"続　柄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒高齢者世帯援助の申請時のみ記入"]
["渋谷　花子",null,null,null,null,null,null,null,null,null,null,null,null,789012,null,null,null,null,null,null,null,"昭和",null,null,7,null,null,"年",null,10,null,"月",null,1,null,"日",null,null,"未申請",null,null,null,"自立",null,null,null,null,"未実施",null,null,null,"非該当",null,null,null,"妻",null,null,null,null,null,null,true,false,false,true,null,null,null,null,"　同居高齢者についての情報を記入（※必ず基本チェックリストを実施の上、ご提出ください。）"]
[]
["地域包括支援センター・ケアマネジャー記入欄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"高齢者世帯援助を選択するとタイトルが黄色になる。しかし、項目を埋めると"]
["派遣開始日",null,null,null,null,null,null,"令和",null,null,null,null,8,null,null,"年",null,3,null,"月",14,null,null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（生年月日のみ日にち、チェックボックスはどちらか選択）すると色付け無しに戻る"]
["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,"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,"継続利用"]
["3,4",null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日のみ",null,null,"毎週",null,null,null,"回 利用",null,null,null,null,null,"月",2,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,null,null,null,true,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,null,null,false,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,null,null,false,false,false,false,false]
[null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",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,null,null,null,false,false,false,false,false]
[]
[]
["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,"外出介助サービス　",null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　"]
[null,null,"１　食事の準備、調理"]
[null,null,"２　洗濯、衣類の整理、補修"]
[null,null,"３　居室等の掃除"]
[null,null,"４　その他　",null,null,null,null,null,"(","買い物代行",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," 同居家族等の存在により介護保険・総合事業の生活援助の全部",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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," 又は一部が受けられないため",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," 同居家族等が援助することができないため",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," 同居家族等の負担軽減が必要なため"]
[]
[]
[]
[null,"〇〇ケアサービス　渋谷",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,"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"]