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["在宅医療資源及び在宅医療の提供等に関する調査\n（訪問リハビリテーション事業所用）"]
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["【調査にあたってのお願い】"]

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["１","【基本情報等について】"]
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["1－①",null,"事業所名称等についてご記入ください。"]
[]
[null,null,"回答者名"]
[]
[]
[null,null,"事業所名称",null,null,null,null,"（ふりがな）"]
[null,null,null,null,null,null,null,"法人名"]
[]
[null,null,null,null,null,null,null,"（ふりがな）"]
[null,null,null,null,null,null,null,"事業所名"]
[]
[null,null,"所在地",null,null,null,null,"（〒",null,null,null,"－",null,null,"）",null,null,null,null,"区"]
[]
[null,null,"連絡先",null,null,null,null,"代　表",null,null,null,null,null,"電話",null,null,null,null,null,null,null,"－"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ",null,null,null,null,null,null,null,"－"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者\n（窓口）"]
[]
[null,null,"ホームページURL"]
[]
[null,null,"外国語対応\n（対応可能な言語に○を記入）",null,null,null,null,null,null,null,null,null,"英",null,null,"中国",null,null,"韓国",null,null,"その他",null,null,"（その他の言語を記載）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（　",null,null,null,null,"　）"]
[]
[]
["1－②",null,"訪問（相談対応）時間等についてご記入ください。"]
[]
[null,null,"訪問時間",null,null,null,null,"曜日",null,"月",null,null,"火",null,null,"水",null,null,"木",null,null,"金",null,null,"土",null,null,"日"]
[]
[null,null,null,null,null,null,null,"午前",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"："]
[null,null,null,null,null,null,null,null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～"]
[null,null,null,null,null,null,null,null,null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"："]
[null,null,null,null,null,null,null,"午後",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"："]
[null,null,null,null,null,null,null,null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～",null,null,"～"]
[null,null,null,null,null,null,null,null,null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"：",null,null,"："]
[null,null,"祝日・盆・年末年始等の対応"]
[]
[]
[]
["1－③",null,"訪問地域についてご記入ください。"]
[]
[null,null,null,null,null,null,"門司区",null,null,"小倉北区",null,null,"小倉南区",null,null,"若松区",null,null,"八幡東区",null,null,"八幡西区",null,null,"戸畑区"]
[]
[null,null,"○を記入",null,"全域"]
[]
[null,null,null,null,"一部"]
[]
[]
["1－④",null,"スタッフの配置状況をご記入ください。（訪問リハビリ部門に限ります）"]
[]
[null,null,"職種",null,null,null,null,null,null,null,null,"人数",null,null,null,null,"左記のうち介護支援専門員を兼務している人数"]
[]
[null,null,"理学療法士"]
[]
[null,null,"作業療法士"]
[]
[null,null,"言語聴覚士"]
[]
[null,null,"その他："]
[]
[null,null,"計",null,null,null,null,null,null,null,null,{"$f":"SUM(L55:P62)","v":0},null,null,null,null,{"$f":"SUM(Q55:Y62)","v":0}]
[]
[]
["1－⑤",null,"訪問を実施するにあたり、条件があればご記入ください。\n　【例】訪問可能日、訪問可能地区・条件など"]
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[]
[]
[]
[]
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[2,"【在宅医療情報について】"]
["2－①",null,"対応可能な疾患について、可能なものに「○」をご記入ください。"]
[]
[null,null,"疾患名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○を記入"]
[null,null,"脳血管疾患"]
[null,null,"運動器疾患（整形疾患）"]
[null,null,"呼吸器疾患"]
[null,null,"心大血管疾患（心臓疾患）"]
[null,null,"神経筋疾患"]
[null,null,"認知症"]
[null,null,"精神疾患"]
[null,null,"癌（末期）"]
[null,null,"廃用症候群"]
[null,null,"小児（脳性麻痺含む）"]
[null,null,"その他（内容）",null,null,null,null,null,"[",null,null,null,null,null,null,null,"]"]
[]
[]
[null,null,"全ての情報を非公表にする。  "]
[]
[]
[null,null,"☆ご協力ありがとうございました。"]