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["傷病手当金請求に係る体調報告書"]
[]
["【 請求期間 】",null,null,"年",null,"月",null,"日","(",null,")","から"]
[null,null,null,"年",null,"月",null,"日","(",null,")","まで"]
[]
["【 傷病名 】"]
[]
["【 当該会社休日 】","① 初めての請求において、請求開始日（当該傷病が理由で３日間連続"]
[null,"　 して休んだ最初の日）が会社休日（※）の場合"]
[null,"② 請求期間の末日が会社休日（※）で、翌日から復職する場合"]
[null,"③ 会社休日（※）付けで退職する場合"]
[null,"④ 請求期間の中で、出勤と欠勤に挟まれた会社休日（※）がある場合"]
[]
[null,"①～④に該当する会社休日を記入してください。"]
[null,null,null,"年",null,"月",null,"日","(",null,")"]
[null,null,null,"年",null,"月",null,"日","(",null,")"]
[null,null,null,"年",null,"月",null,"日","(",null,")"]
[]
[]
["【 体　調 】","上記会社休日（※）における体調について、下記１・２それぞれ該当"]
[null,"するものに✔を記入してください。"]
[]
["１．","□","普通の生活ができた"]
[null,"□","ときどき散歩に出るくらいで、ほとんど家の中にいた"]
[null,"□","身の回りのことはできたが、一日中家の中にいた"]
[null,"□","身の回りのことはかろうじてできたが、一日中床についていた"]
[null,"□","身の回りのことも家族の介助が必要で、一日中床についていた"]
[null,"□","その他 [友人や家族と出かけたり、ショッピング・趣味等ひとりで出かけた]"]
[]
["２．","□","労務可能な状況であった"]
[null,"□","労務不能な状況であった"]
[]
[]
[{"$nulls":13},"年",null,"月",null,"日"]
[{"$nulls":9},"記号-番号",{"$nulls":4},"－"]
[{"$nulls":9},"被保険者氏名"]