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["様式1"]
[]
["医療情報システム利用申請書"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請日"]
["独立行政法人国立病院機構信州上田医療センター\n　　　　　　 　　　　情報システム管理者　殿　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
["以下の通り、独立行政法人国立病院機構信州上田医療センター医療情報システムの利用を申請します。\n（権限の変更、利用停止、再開についてもこの様式を利用して申請します。）\n                                                                      ※太枠内を記入してください"]
[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,"職場長\n (診療科長）",null,null,null,null,null,null,"\n"]
[]
["申請区分\n該当する番号に○をつけてください",null,null,null,null,null,null,"1.新規 ・ 2.変更 ・ 3.利用停止 ・ 4.利用再開"]
[]
[]
["職員区分",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,"昭和\n\n平成 ",null,null,null,"年",null,null,null,"月",null,null,"日"]
["フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性　　別",null,null,null,null,"男　・　女"]
["利用者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所属部署"]
[]
["所属",null,null,null,null,"※所属が信州上田医療センター以外の方は下記に記入してください。　　　例：○○病院　○○科"]
[]
["職　種"]
["連絡先",null,null,null,null,"内線　・　PHS　（　　　　　）",null,null,null,null,null,null,null,null,null,null,null,"備考\n(変更点等)"]
["利用者ID",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"←（新規、再開時は医療情報部担当者にて記入）",null,null,null,null,null,null,"過去の採用\n有無",null,null,null,null,"有　・　無"]
["使用開始日",null,null,null,null,"令和　",null,null,null,"年",null,null,"月",null,null,"日",null,"使用終了日",null,null,null,null,"令和",null,null,null,"年",null,null,null,"月",null,null,"日"]
["注１）申請区分･･･「変更」の際はその詳細を「備考」欄に記入すること。（異動先部署、改姓前後氏名等）"]
["注２）利用者ＩＤ･･･申請区分が「新規」以外の時、現在利用中、又は過去に利用していたＩＤを記入すること。"]
["注３）使用開始日は、当センターへの採用日又は上記の職種に就いた日等を正確に記入すること。"]
["注４）本申請書の承認後、利用者に対して利用者ＩＤ及び仮パスワードを通知します。"]
["注５）本申請書は原則、利用開始日の7診療日前までに提出すること。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申請者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"印"]
[]
[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,"(申請者自署の場合印鑑省略可)"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"【以下　決裁欄】"]
[]
["上記の通り、承認する"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"院長",null,null,"事務部長",null,null,"医療情報部長",null,null,"医療情報係長",null,null,"担当者"]
[null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
[]
["独立行政法人国立病院機構信州上田医療センター"]
["                  情報システム管理者"]
["                                院長"]