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[]
[null,"指定（介護予防）訪問入浴介護事業所事前提出書類"]
[]
[]
[]
[null,"〇　事業所名"]
[]
[]
[null,"〇　サービスの提供状況"]
[null,"提供月",null,null,null,null,null,null,"年",{"$f":"IF(H10=\"\",\"\",IF(AND(H10=\"R3\",H11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(J10=\"\",\"\",IF(AND(J10=\"R3\",J11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(L10=\"\",\"\",IF(AND(L10=\"R3\",L11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(N10=\"\",\"\",IF(AND(N10=\"R3\",N11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(P10=\"\",\"\",IF(AND(P10=\"R3\",P11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(R10=\"\",\"\",IF(AND(R10=\"R3\",R11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(T10=\"\",\"\",IF(AND(T10=\"R3\",T11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(V10=\"\",\"\",IF(AND(V10=\"R3\",V11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(X10=\"\",\"\",IF(AND(X10=\"R3\",X11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(Z10=\"\",\"\",IF(AND(Z10=\"R3\",Z11<12),\"R3\",\"R4\"))","v":""},"年",{"$f":"IF(AB10=\"\",\"\",IF(AND(AB10=\"R3\",AB11<12),\"R3\",\"R4\"))","v":""},"年"]
[null,null,null,null,null,null,null,null,"月",{"$f":"IF(H11=\"\",\"\",IF(H11=12,1,H11+1))","v":""},"月",{"$f":"IF(J11=\"\",\"\",IF(J11=12,1,J11+1))","v":""},"月",{"$f":"IF(L11=\"\",\"\",IF(L11=12,1,L11+1))","v":""},"月",{"$f":"IF(N11=\"\",\"\",IF(N11=12,1,N11+1))","v":""},"月",{"$f":"IF(P11=\"\",\"\",IF(P11=12,1,P11+1))","v":""},"月",{"$f":"IF(R11=\"\",\"\",IF(R11=12,1,R11+1))","v":""},"月",{"$f":"IF(T11=\"\",\"\",IF(T11=12,1,T11+1))","v":""},"月",{"$f":"IF(V11=\"\",\"\",IF(V11=12,1,V11+1))","v":""},"月",{"$f":"IF(X11=\"\",\"\",IF(X11=12,1,X11+1))","v":""},"月",{"$f":"IF(Z11=\"\",\"\",IF(Z11=12,1,Z11+1))","v":""},"月",{"$f":"IF(AB11=\"\",\"\",IF(AB11=12,1,AB11+1))","v":""},"月"]
[null,"介護予防利用者数"]
[]
[null,"訪問入浴利用者数"]
[]
[null,"（注）　利用者数は、介護報酬請求に係る実利用者数を記入してください。（直近12か月分）"]
[]
[]
[null,"初回加算",null,null,null,null,null,null,null,"　有　・　　無",null,null,null,null,null,null,"認知症専門ケア加算",null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"特別地域加算",null,null,null,null,null,null,null,"　有　・　　無"]
[]
[null,"中山間地域等における小規模事業所加算（地域に関する状況）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　該当　・　　非該当"]
[]
[null,"中山間地域等における小規模事業所加算（規模に関する状況）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　該当　・　　非該当"]
[]
[null,"サービス提供体制強化加算",null,null,null,null,null,null,null,"　有［　　Ⅰ　・　　Ⅱ　・　　Ⅲ　］・　　無"]
[]
[null,"介護職員処遇改善加算",null,null,null,null,null,null,null,"　有［　　Ⅰ　・　　Ⅱ　・　　Ⅲ　］・　　無"]
[]
[null,"介護職員等特定処遇改善加算",null,null,null,null,null,null,null,"　有［　　Ⅰ　・　　Ⅱ　　］・　　無"]
[]
[null,"介護職員等ベースアップ等\n　　　　　　　　　支援加算",null,null,null,null,null,null,null,"　有　　・　　無"]