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["事 故 発 生 状 況 報 告 書"]
["別紙交通事故証明書に補足して下記のとおり報告いたします。"]
["甲（加害運転者）氏名",null,null,null,"乙（被害者）氏名",null,null,null,"運転・同乗",null,"甲車"]
[]
[{"$nulls":10},"甲車以外の車"]
[{"$nulls":8},"歩行・その他"]
["速 度","甲車　　　　ｋｍ/ｈ（制限速度　　　　　ｋｍ/ｈ）、甲車以外の車　　　　ｋｍ/ｈ（制限速度　　　　　ｋｍ/ｈ）"]
["事故現場における衝突までの状況を図示して下さい",null,"事故発生状況略図（通路幅をmで記入してください）"]
[]
[{"$nulls":9},"×","衝突地点"]
[{"$nulls":10},"甲車輛"]
[{"$nulls":10},"乙車輛"]
[{"$nulls":10},"自ニ・原付"]
[{"$nulls":10},"自転車"]
[{"$nulls":10},"歩行者、人"]
[{"$nulls":10},"甲の進路"]
[{"$nulls":9},"●","乙の進路"]
[{"$nulls":10},"信号機"]
[{"$nulls":10},"一時停止標識"]
[{"$nulls":10},"その他の標識"]
[{"$nulls":10},"ｶﾞｰﾄﾞﾚｰﾙ等"]
[{"$nulls":10},"横断歩道"]
[{"$nulls":9},"～ ～\n～ ～\n～ ～","橋梁"]
[{"$nulls":10},"ｶｰﾌﾞﾐﾗｰ等"]
["上図の説明を書いて下さい","（詳しく）"]
["甲車以外の車について判明している場合、ご記入下さい。"]
["自動車の番号",{"$nulls":4},"運 転 者","氏  名\n（電話）"]
["保　　有　　者",null,"〒\n住所",{"$nulls":4},"氏  名\n（電話）"]
[null,"　　　　年　　　月　　　日"]
[{"$nulls":4},"甲との関係","(",")"]
[null,null,null,"報 告 者","又は","  ",null,"氏名",null,null,"㊞"]
[{"$nulls":4},"乙との関係","(",")"]