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{"sheet":"時間延長等変更申請書 (入力用)","index":0,"n_rows":44,"n_cols":67,"rows_kept":44,"cut":false,"hidden":false,"merged":[[9,51,9,53],[7,0,8,0],[5,0,5,8],[5,27,5,34],[5,36,5,57],[6,1,6,23],[6,27,6,34],[6,36,6,57],[7,27,7,31],[7,34,7,37],[7,38,7,57],[8,27,8,31],[8,34,8,57],[9,54,9,55],[9,56,9,57],[9,49,9,50],[9,43,9,44],[7,1,9,23],[16,33,17,56],[11,27,11,37],[11,40,11,41],[11,47,11,48],[0,52,1,53],[0,54,1,55],[0,56,1,57],[3,0,4,8],[3,35,3,57],[4,27,4,34],[4,36,4,57],[0,0,0,12],[0,35,1,39],[0,40,1,43],[0,44,1,47],[0,48,1,49],[0,50,1,51],[2,0,2,57],[9,27,9,31],[9,37,9,38],[9,39,9,40],[9,41,9,42],[9,45,9,46],[9,47,9,48],[16,5,16,8],[16,1,16,4],[23,0,23,3],[23,4,23,25],[19,0,19,23],[20,14,20,16],[24,0,24,3],[10,1,10,21],[10,22,10,23],[14,17,14,56],[15,13,15,29],[14,2,14,11],[15,2,15,8],[18,13,18,23],[18,24,18,48],[15,9,15,12],[15,32,15,35],[15,36,15,50],[13,0,13,42],[14,13,14,16],[10,27,10,35],[10,40,10,41],[10,47,10,48],[16,9,17,29],[43,38,43,42],[43,43,43,56],[38,0,38,57],[39,0,39,57],[40,0,40,57],[42,43,42,56],[42,1,43,24],[42,26,42,36],[42,38,42,42],[43,26,43,36],[36,0,36,57],[37,0,37,57],[29,0,29,3],[30,0,30,48],[31,0,31,25],[29,17,29,18],[29,19,29,22],[29,54,29,56],[29,51,29,53],[29,23,29,26],[29,27,29,30],[29,31,29,35],[29,40,29,46],[29,4,29,16],[29,36,29,39],[29,47,29,50],[32,0,32,8],[33,35,33,47],[35,28,35,54],[35,56,35,57],[20,17,20,19],[20,20,20,22],[20,23,20,24],[28,47,28,56],[25,21,25,22],[24,34,24,36],[26,34,26,36],[27,0,27,9],[28,0,28,3],[26,26,26,29],[26,30,26,31],[26,0,26,3],[26,4,26,17],[26,18,26,20],[26,21,26,22],[28,23,28,46],[28,4,28,22],[24,4,24,17],[24,18,24,20],[24,21,24,22],[20,5,20,8],[20,9,20,11],[20,12,20,13],[25,0,25,3],[25,4,25,17],[25,18,25,20],[21,0,21,57],[23,44,23,56],[23,26,23,32],[23,33,23,43],[22,0,22,9],[26,53,26,56],[24,50,24,52],[25,50,25,52],[24,53,24,56],[25,53,25,56],[26,50,26,52],[25,34,25,36],[25,30,25,31],[24,30,24,31],[24,26,24,29],[25,26,25,29]]}
["別記第４号様式（第９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,"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,"⇒記入日を記入"]
[]
["介護予防訪問介護サービス 時間延長等 事業利用 変 更 申 請 書 兼 派遣指示書"]
["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,"（　　事業対象者　　　　要支援 1 　　　要支援 2）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false,false,null,null,null,null,null,"⇒該当の認定区分に☑をいれる。"]
[null,null,null,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,"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,"⇒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,"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,"住　　　所　　",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,{"$f":"IF(BG10=TRUE,AN10+1867,)","v":0},{"$f":"IF(BH10=TRUE,AN10+1911,)","v":0},{"$f":"IF(BI10=TRUE,AN10+1925,0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,BG8,IF(BH10=TRUE,BH8,BI8))","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,"生年月日",null,null,null,null,"　","明",null,"大",null,"昭",null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"年齢（",null,null,{"$f":"IF(AV10=\"\",\"\",DATEDIF(BG9&\"年\"&AR10&\"月\"&AV10&\"日\",TODAY(),\"Y\"))","v":""},null,"歳）",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,"殿",null,null,null,null,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",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,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",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,"⇒押印は不要となりました。"]
["《該当する□にレ印をつけ、変更内容を記入してください。》"]
[null,null,"住所の変更　新住所",null,null,null,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,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,"⇒【住所の変更】住所に変更がある場合、☑をいれ、新しい住所を記入"]
[null,null,"事業者の変更　",null,null,null,null,null,null,"(現行)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(変更後)",null,null,null,"※継続利用の事業者も記入",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,"⇒【事業者の変更】事業者を変更又は追加する場合、該当項目に☑をいれ、今後利用する事業者を全て記入"]
[null,"（　　変更",null,null,null,"追加）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"　　（現行）現在利用中の事業者を全て記入"]
[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,"　　（変更後）今後利用する事業者を全て記入　※現在の事業者も継続する場合は現在の事業者も記入"]
[null,null,"派遣内容の変更",null,null,null,null,null,null,null,null,null,null,"※ 詳細は以下に記入",null,null,null,null,null,null,null,null,null,null,"（継続利用のサービスも記入してください。）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒【派遣内容の変更】点線以下（派遣開始日以降）の派遣内容に変更がある場合に☑をいれる。"]
["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,"令和",null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,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。）"]
["　　　時 間 延 長　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派遣希望回数",null,null,null,null,null,null,"派 遣 希 望 時 間 数",null,null,null,null,null,null,null,null,null,null,"派　遣　状　況"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,"週",null,null,null,null,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続",null,null,null,null,false,false,false,false,false]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,"週",null,null,null,null,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続",null,null,null,null,false,false,false,false,false]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,"週",null,null,null,null,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続",null,null,null,null,false,false,false,false,false]
["　　　回 数 追 加",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派　遣　状　況"]
[null,null,null,null,"国基準訪問サービス　週",null,null,null,null,null,null,null,null,null,null,null,null,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,"変更",null,null,null," 追加",null,null,"継続",null,null,null,false,false,false,false,false,false,false,false]
["※　派遣開始日時点の総合事業の利用回数をご記入ください。"]
["該当する□全てにレ印をつけてください。"]
["① サービス内容"]
[null,null,null,null,"１　食事の準備、調理",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２　洗濯、衣類の整理、補修",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"３　居室等の掃除"]
[null,null,null,null,"４　身体介護［",null,null,null,null,null,null,null,null,null,null,"食事介助",null,null,null,null,null,null,null,"入浴介助",null,null,null,null,null,null,"身体整容",null,null,null,null,null,"通院・外出介助",null,null,null,null,null,null,null,null,null,null,"服薬介助"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"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,false]
["② サービスが必要な理由　（利用者の状態、期待される効果等）"]
[]
[]
[]
[]
[]
[null,null,null,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,"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,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,"連絡先："]

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["別記第４号様式（第９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,"令和",null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,"⇒記入日を記入"]
[]
["介護予防訪問介護サービス 時間延長等 事業利用 変 更 申 請 書 兼 派遣指示書"]
["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,"（　　事業対象者　　　　要支援 1 　　　要支援 2）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false,false,"⇒該当の認定区分に☑をいれる。"]
[null,null,null,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,"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,"⇒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,"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,"住　　　所　　",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,{"$f":"IF(BG10=TRUE,AN10+1867,)","v":0},{"$f":"IF(BH10=TRUE,AN10+1911,)","v":0},{"$f":"IF(BI10=TRUE,AN10+1925,0)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,BG8,IF(BH10=TRUE,BH8,BI8))","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,"生年月日",null,null,null,null,"　","明",null,"大",null,"昭",null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"年齢（",null,null,{"$f":"IF(AV10=\"\",\"\",DATEDIF(BG9&\"年\"&AR10&\"月\"&AV10&\"日\",TODAY(),\"Y\"))","v":""},null,"歳）",null,false,false,false,"⇒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,"殿",null,null,null,null,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",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,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",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,"⇒押印は不要となりました。"]
["《該当する□にレ印をつけ、変更内容を記入してください。》"]
[null,null,"住所の変更　新住所",null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,null,null,"⇒【住所の変更】住所に変更がある場合、☑をいれ、新しい住所を記入"]
[null,null,"事業者の変更　",null,null,null,null,null,null,"(現行)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(変更後)",null,null,null,"※継続利用の事業者も記入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,null,null,"⇒【事業者の変更】事業者を変更又は追加する場合、該当項目に☑をいれ、今後利用する事業者を全て記入"]
[null,"（　　変更",null,null,null,"追加）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"　　（現行）現在利用中の事業者を全て記入"]
[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,"　　（変更後）今後利用する事業者を全て記入　※現在の事業者も継続する場合は現在の事業者も記入"]
[null,null,"派遣内容の変更",null,null,null,null,null,null,null,null,null,null,"※ 詳細は以下に記入",null,null,null,null,null,null,null,null,null,null,"（継続利用のサービスも記入してください。）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒【派遣内容の変更】点線以下（派遣開始日以降）の派遣内容に変更がある場合に☑をいれる。"]
["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,"令和",null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,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。）"]
["　　　時 間 延 長　　"]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派遣希望回数",null,null,null,null,null,null,"派 遣 希 望 時 間 数",null,null,null,null,null,null,null,null,null,null,"派　遣　状　況"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,"週",null,null,null,null,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,"週",null,null,null,null,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,"週",null,null,null,null,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続"]
["　　　回 数 追 加"]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派　遣　状　況"]
[null,null,null,null,"国基準訪問サービス　週",null,null,null,null,null,null,null,null,null,null,null,null,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,"変更",null,null,null," 追加",null,null,"継続"]
["※　派遣開始日時点の総合事業の利用回数をご記入ください。"]
["該当する□全てにレ印をつけてください。"]
["① サービス内容"]
[null,null,null,null,"１　食事の準備、調理",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２　洗濯、衣類の整理、補修",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"３　居室等の掃除"]
[null,null,null,null,"４　身体介護［",null,null,null,null,null,null,null,null,null,null,"食事介助",null,null,null,null,null,null,null,"入浴介助",null,null,null,null,null,null,"身体整容",null,null,null,null,null,"通院・外出介助",null,null,null,null,null,null,null,null,null,null,"服薬介助"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"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,false]
["② サービスが必要な理由　（利用者の状態、期待される効果等）"]
[]
[]
[]
[]
[]
[null,null,null,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,"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,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,"連絡先："]

{"sheet":"時間延長等変更申請書 (記入例)","index":2,"n_rows":44,"n_cols":62,"rows_kept":44,"cut":false,"hidden":false,"merged":[[36,0,36,57],[37,0,37,57],[38,0,38,57],[39,0,39,57],[40,0,40,57],[43,26,43,36],[43,38,43,42],[42,1,43,24],[42,26,42,36],[42,38,42,42],[42,43,42,56],[43,43,43,56],[30,0,30,48],[31,0,31,25],[32,0,32,8],[33,35,33,47],[35,28,35,54],[35,56,35,57],[29,31,29,35],[29,36,29,39],[29,40,29,46],[29,47,29,50],[29,51,29,53],[29,54,29,56],[29,0,29,3],[29,4,29,16],[29,17,29,18],[29,19,29,22],[29,23,29,26],[29,27,29,30],[26,53,26,56],[27,0,27,13],[28,0,28,3],[28,4,28,22],[28,23,28,46],[28,47,28,56],[25,50,25,52],[25,53,25,56],[26,0,26,3],[26,4,26,17],[26,18,26,20],[26,21,26,22],[26,26,26,29],[26,30,26,31],[26,34,26,36],[26,50,26,52],[24,34,24,36],[24,50,24,52],[24,53,24,56],[25,0,25,3],[25,4,25,17],[25,18,25,20],[25,21,25,22],[25,26,25,29],[25,30,25,31],[25,34,25,36],[24,0,24,3],[24,4,24,17],[24,18,24,20],[24,21,24,22],[24,26,24,29],[24,30,24,31],[21,0,21,57],[22,0,22,57],[23,0,23,3],[23,4,23,25],[23,26,23,32],[23,33,23,43],[23,44,23,56],[18,13,18,23],[18,24,18,48],[19,0,19,23],[20,5,20,8],[20,9,20,11],[20,12,20,13],[20,14,20,16],[20,17,20,19],[20,20,20,22],[20,23,20,24],[15,2,15,8],[15,9,15,12],[15,13,15,29],[15,32,15,35],[15,36,15,50],[16,1,16,4],[16,5,16,8],[16,9,17,29],[16,33,17,56],[11,27,11,37],[11,40,11,41],[11,47,11,48],[12,0,12,58],[13,0,13,42],[14,2,14,11],[14,13,14,16],[14,17,14,56],[9,54,9,55],[9,56,9,57],[10,1,10,21],[10,22,10,23],[10,27,10,35],[10,40,10,41],[10,47,10,48],[9,41,9,42],[9,43,9,44],[9,45,9,46],[9,47,9,48],[9,49,9,50],[9,51,9,53],[7,0,8,0],[7,1,9,23],[7,27,7,31],[7,34,7,37],[7,38,7,57],[8,27,8,31],[8,34,8,57],[9,27,9,31],[9,37,9,38],[9,39,9,40],[5,0,5,8],[5,27,5,34],[5,36,5,57],[6,1,6,23],[6,27,6,34],[6,36,6,57],[0,52,1,53],[0,54,1,55],[0,56,1,57],[2,0,2,58],[3,0,4,8],[3,35,3,57],[4,27,4,34],[4,36,4,57],[0,0,0,12],[0,35,1,39],[0,40,1,43],[0,44,1,47],[0,48,1,49],[0,50,1,51]]}
["別記第４号様式（第９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,"令和",null,null,null,8,null,null,null,"年",null,3,null,"月",null,1,null,"日",null,null,null,null,"⇒記入日を記入"]
[]
["介護予防訪問介護サービス 時間延長等 事業利用 変 更 申 請 書 兼 派遣指示書"]
["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,"（　　事業対象者　　　　要支援 1 　　　要支援 2）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false,true,"⇒該当の認定区分に☑をいれる。"]
[null,null,null,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,"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,"氏名",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,"⇒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,"被保険者番号",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,"住　　　所　　",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,{"$f":"IF(BG10=TRUE,AN10+1867,)","v":0},{"$f":"IF(BH10=TRUE,AN10+1911,)","v":0},{"$f":"IF(BI10=TRUE,AN10+1925,0)","v":1932}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,null,null,"03-3463-1873",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(BG10=TRUE,BG8,IF(BH10=TRUE,BH8,BI8))","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,"生年月日",null,null,null,null,"　","明",null,"大",null,"昭",null,7,null,"年",null,10,null,"月",null,1,null,"日",null,"年齢（",null,null,{"$f":"IF(AV10=\"\",\"\",DATEDIF(BG9&\"年\"&AR10&\"月\"&AV10&\"日\",TODAY(),\"Y\"))","v":93},null,"歳）",null,false,false,true,"⇒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,"殿",null,null,null,null,"同居家族の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",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,"生活保護受給の有無",null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,true,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,"⇒押印は不要となりました。"]
["《該当する□にレ印をつけ、変更内容を記入してください。》"]
[null,null,"住所の変更　新住所",null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,null,null,"⇒【住所の変更】住所に変更がある場合、☑をいれ、新しい住所を記入"]
[null,null,"事業者の変更　",null,null,null,null,null,null,"(現行)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(変更後)",null,null,null,"※継続利用の事業者も記入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,true,null,null,"⇒【事業者の変更】事業者を変更又は追加する場合、該当項目に☑をいれ、今後利用する事業者を全て記入"]
[null,"（　　変更",null,null,null,"追加）",null,null,null,"ホームヘルプ△△",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,false,true,null,"　　（現行）現在利用中の事業者を全て記入"]
[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,"　　（変更後）今後利用する事業者を全て記入　※現在の事業者も継続する場合は現在の事業者も記入"]
[null,null,"派遣内容の変更",null,null,null,null,null,null,null,null,null,null,"※ 詳細は以下に記入",null,null,null,null,null,null,null,null,null,null,"（継続利用のサービスも記入してください。）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"⇒【派遣内容の変更】点線以下（派遣開始日以降）の派遣内容に変更がある場合に☑をいれる。"]
["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,"令和",null,null,null,8,null,null,"年",null,3,null,null,"月",null,null,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。）"]
["　　　時 間 延 長　　"]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派遣希望回数",null,null,null,null,null,null,"派 遣 希 望 時 間 数",null,null,null,null,null,null,null,null,null,null,"派　遣　状　況"]
[4,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,2,null,null,"回",null,"利用",null,null,"週",null,null,null,2,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,"週",null,null,null,null,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続"]
[null,null,null,null,"国基準訪問サービス　　週",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"回",null,"利用",null,null,"週",null,null,null,null,null,"回",null,"３０分",null,null,null,null,"１時間",null,null,null,null,null,null,"変更",null,null,null,"追加",null,null,"継続"]
["　　　回 数 追 加"]
["① サービス内　容No.",null,null,null,"総合事業の利用回数 （※）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"派　遣　状　況"]
[null,null,null,null,"国基準訪問サービス　週",null,null,null,null,null,null,null,null,null,null,null,null,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,"変更",null,null,null," 追加",null,null,"継続"]
["※　派遣開始日時点の総合事業の利用回数をご記入ください。"]
["該当する□全てにレ印をつけてください。"]
["① サービス内容"]
[null,null,null,null,"１　食事の準備、調理",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２　洗濯、衣類の整理、補修",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"３　居室等の掃除"]
[null,null,null,null,"４　身体介護［",null,null,null,null,null,null,null,null,null,null,"食事介助",null,null,null,null,null,null,null,"入浴介助",null,null,null,null,null,null,"身体整容",null,null,null,null,null,"通院・外出介助",null,null,null,null,null,null,null,null,null,null,"服薬介助"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"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,"）","］"]
["② サービスが必要な理由　（利用者の状態、期待される効果等）"]
["　"]
[]
[]
[]
[]
[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,null,null,null,"地域包括支援センター",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,null,null,null,"居宅介護支援事業所",null,null,null,null,null,null,null,null,null,null,null,"連絡先：",null,null,null,null,"03-3463-xxxx"]