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[{"$nulls":6},"　年   　　月 　  　日"]
["ク ラ ブ プ ラ ッ ツ 事 故 報 告 書"]
["事業名",null,null,null,"取扱担当者　　　　　　　　　　　　　　　　　　　"]
[{"$nulls":4},"事業担当責任者　　　　　　　　　　　　　　　　"]
[]
["事故発生日時",null,"年　　　　　月　　　　　　日（　　）　　　　　時　　　　　分頃"]
["事故発生場所"]
["応急対応者",null,null,"対処"]
["応急２次対応者",null,null,"対処"]
["救急車要請",null,"なし　　　・　　あり　（要請時間　　　　　時　　　　　　分頃）　　　　"]
["被災者名",null,null,null,"年齢","才",null,"性別","男・女"]
["連絡先電話番号"]
["連絡先住所"]
["事故発生状況"]
[]
[]
[]
[]
["保険対応",null,"　　選択　→　　　　　　　　希望する　・　希望しない"]
["特記"]
[]
[]
[]
[{"$nulls":4},"事業部長","C　D",null,"理事長","事務局"]