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[null,null,null,"「医療措置協定」の締結に係る事前回答票\n （薬局用）",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"薬局用"]
[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,null,"…必須回答欄です"]
[]
[]
[]
[null,"第１　基本情報を入力してください。",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,"第３　「個人防護具の備蓄」について入力してください。"]
[null,null,"１　薬局名",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,"１　個人防護具の備蓄について"]
[null,null,"２　管理者（管理薬剤師）氏名",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,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(S20=\"否\",\"【「個人防護具の備蓄」のみでの協定締結はできません】\",IF(AW7=\"否\",\"【以下は入力不要・第4へ進んでください】\",\"↓　　　　　　　　\"))","v":"↓　　　　　　　　"}]
[null,null,"３　担当者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"２　各物資の備蓄数量・期間を入力してください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（備蓄を行わない物資については「0」をご記入ください）"]
[null,null,"４　郵便番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・サージカルマスク",null,null,null,null,null,null,null,null,null,null,null,"枚","×",null,null,null,"か月分",null,"=",{"$f":"AR10*AW10","v":0},null,null,"枚"]
[null,null,"５　所在地",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,null,"・Ｎ95マスク",null,null,null,null,null,null,null,null,null,null,null,"枚","×",null,null,null,"か月分",null,"=",{"$f":"AR11*AW11","v":0},null,null,"枚"]
[null,null,"６　電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・アイソレーションガウン",null,null,null,null,null,null,null,null,null,null,null,"枚","×",null,null,null,"か月分",null,"=",0,null,null,"枚"]
[null,null,"７　メールアドレス",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・フェイスシールド",null,null,null,null,null,null,null,null,null,null,null,"枚","×",null,null,null,"か月分",null,"=",0,null,null,"枚"]
[null,null,"８　ファックス番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・非滅菌手袋",null,null,null,null,null,null,null,null,null,null,null,"枚","×",null,null,null,"か月分",null,"=",0,null,null,"枚"]
[null,null,"９　保険薬局コード",null,null,null,null,null,null,null,null,null,null,null,null,null,"（10ケタ・未定時は「未定」と入力）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",{"$f":"AR14/2","v":0},null,"双","×",{"$f":"AW14","v":0},null,null,"か月分",null,"=",{"$f":"AS15*AW15","v":0},null,"双）"]
[null,null,"10　G-MIS ID",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,null,null,null,null,null,null,null,null,"　１月当たりの枚数　",null,null,null,null,null,"協定書には太字部分の値を記載します。"]
[]
[]
[null,"第２　「自宅療養者等への医療の提供」について入力してください。",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,"第４　その他事項・第二種協定指定医療機関への指定について"]
[null,null,"１　自宅療養者等への医療の提供について",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,"１　その他事項があればご入力ください。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(S20=\"否\",\"【「否」の場合は医療措置協定を締結することが出来ません】\",\"↓　　   　　　　　　　\")","v":"↓　　   　　　　　　　"}]
[null,null,"２　以下の事項について、対応の可否を入力してください。"]
[null,null,null,"施設内療養者への対応",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,"２　第二種協定指定医療機関への指定について"]
[null,null,null,null,"・高齢者施設における施設内療養者への対応",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,"医療措置協定にあわせて、感染症法の規定に基づき「第二種協定指定医療機関」への指定も行います。（指定に当たっては以下の指定要件を満たす必要があります。）"]
[null,null,null,null,"・障害者施設における施設内療養者への対応",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"開設者氏名"]
[null,null,null,"その他対応"]
[null,null,null,null,"・オンライン服薬指導（電話のみ）"]
[null,null,null,null,"・オンライン服薬指導（ビデオ通話）",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,"第二種協定指定医療機関の指定要件"]
[null,null,null,null,"・訪問服薬指導",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,"＜外出自粛対象者への医療提供（自宅療養者等への医療提供）＞"]
[null,null,null,null,"・薬剤等の配送",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,"当該薬局に所属する者に対して、最新の知見に基づき適切な感染防止等の措置を実施することが可能であること。"]
[null,null,"３　特記事項があればご入力ください。",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,"新型インフルエンザ等感染症等発生等公表期間において、都道府県知事からの要請を受けて、外出自粛対象者に\n　対して医薬品等対応（調剤・医薬品 等交付・服薬指導等）を行う体制が整っていると認められること。"]
[]
[]
[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,null,"※ご入力いただいた事前回答票は三重県ホームページの回答フォームからご提出下さい。"]
[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,null,"　（お問い合わせ先：三重県医療保健部　感染症対策課　☎：059-224-2352（平日8:30～17:15））"]