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[null,null,"　事故報告書　（事業者→東吉野村）"]
[]
[null,null,"※第１報は、少なくとも1から6までについては可能な限り記載し、事故発生後速やかに、遅くとも５日以内を目安に提出すること"]
[null,null,"※選択肢については該当する項目をチェックし、該当する項目が複数ある場合は全て選択すること"]
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[null,null,"所在地",{"$nulls":14},"特定施設入居者生活介護"]
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[null,null,"電話番号",{"$nulls":4},"被保険者番号",{"$nulls":9},"軽費老人ホーム"]
[null,null,"身体状況","要介護度",null,null,"☐","☐","☐","☐","☐","☐","☐","☐",null,null,null,"有料老人ホーム"]
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[null,null,null,"☐","敷地外",null,"☐","その他（　　　　　　　　　　　　　　）"]
[null,null,"事故の種別","☐","転倒",null,"☐","異食",null,null,"☐","不明"]
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[null,null,null,"☐","誤嚥・窒息",null,"☐","医療処置関連（チューブ抜去等）",null,null,"☐","食中毒・感染症（　　　　　　　　　）"]
[null,null,"普段の様子、発生時状況、事故内容の詳細"]
[null,null,"その他\n特記すべき事項"]
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[null,null,null,"☐","その他（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,null,"検査、処置等の概要"]
[null,"6事故発生後の状況","利用者の状況"]
[null,null,"家族等への報告","報告した家族等の\n続柄",null,"☐","配偶者","☐","子、子の配偶者",null,"☐","その他（",null,null,"）"]
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[null,null,null,"家族の反応・発言等"]
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[null,null,"本人、家族、関係先等\nへの追加対応予定"]
[null,"7 事故の原因分析\n（本人要因、職員要因、環境要因の分析）",null,null,"（できるだけ具体的に記載すること）"]
[]
[null,"8 再発防止策\n（手順変更、環境変更、その他の対応、\n再発防止策の評価時期および結果等）",null,null,"（できるだけ具体的に記載すること）"]
[]
[null,"9 その他\n特記すべき事項"]