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["治療と職業生活の両立支援申込書"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"平成",null,"年",null,"月",null,"日"]
["事業場名"]
["業種",null,null,null,null,null,null,null,"事業内容",null,null,null,null,null,null,null,"労働者数",null,null,null,null,null,"人"]
["所在地",null,null,"〒"]
[]
[null,null,null,"ＴＥＬ",null,null,null,null,null,null,null,null,null,"ＦＡＸ"]
["担当者",null,null,"部署名",null,null,null,null,null,null,null,null,null,"氏名"]
[null,null,null,"E-mail"]
[null,null,null,"職種",null,null,"産業医",null,null,null,null,null,"保健師・看護師",null,null,null,null,null,"事業主"]
[null,null,null,null,null,null,"労務管理担当",null,null,null,null,null,"衛生管理者",null,null,null,null,null,"労働者（患者）"]
[null,null,null,null,null,null,"その他（",null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["希望する支援内容",null,null,null,null," □にチェックを入れ、希望する番号に○印を付けてください。"]
[null,"個別訪問支援"]
[null,"✽担当者が事業場を訪問し、両立支援に関する制度の導入等についてアドバイスします。"]
[null,1,"管理監督者向け両立支援教育 （事業場の管理監督者や労働者等に対し、意識啓発を行うセミナー）"]
[null,2,"事業場内体制の整備",null,null,null,null,null,null,null,null,null,3,"事業場内規程等の整備"]
[null,4,"事業場の勤務、休暇制度の整備",null,null,null,null,null,null,null,null,null,5,"両立支援の進め方"]
[null,6,"両立支援に係る情報提供"]
[null,7,"その他（具体的に：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,"啓発セミナー"]
[null,"✽ガイドライン等の普及・啓発を目的とした事業者等を対象とするセミナーです。"]
[]
[null,"個別調整支援（ご本人の同意が必要）"]
[null,"✽事業場と労働者（患者）間の、仕事と治療の両立についてアドバイスします。"]
[null,1,"労働者（患者）との治療に対する配慮の検討",null,null,null,null,null,null,null,null,null,2,"両立支援の進め方"]
[null,3,"両立支援プランの作成",null,null,null,null,null,null,null,null,null,4,"職場復帰支援プランの作成"]
[null,5,"主治医等への相談",null,null,null,null,null,null,null,null,null,6,"就業上の措置についての検討"]
[null,7,"その他（具体的に：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["【申込先】独立行政法人労働者健康安全機構　京都産業保健総合支援センター"]
["ＦＡＸ：０７５－２１２－２７００"]
["※申込書受領後、当センターからご連絡いたします。"]
["※この用紙に記載された個人情報は、産業保健活動総合支援事業の目的以外には使用いたしません。　"]