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["あて先：ＦＡＸ　０１７－７３１－３６６０（青森産業保健総合支援センターあて）"]
["　　　 Ｅ-mail ：sanpo02@aomoris.johas.go.jp"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"利　用　申　込　書"]
[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,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
["事業場名\n（団体名)",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,"労働者数"]
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["代 表 者",null,null,null,null,"職名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"名"]
[]
[null,null,null,null,null,"〒",null,null,null,"-"]
["所 在 地"]
[null,null,null,null,null,"電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ番号"]
[null,null,null,null,null,null,null,"（",null,null,null,null,"）",null,null,null,null,"ー",null,null,null,null,null,null,"（",null,null,null,null,"）",null,null,null,null,"ー"]
[null,null,null,null,null,"所属",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名"]
["担 当 者"]
[null,null,null,null,null,null,"Ｅ－mail",null,null,null,":"]
[]
["業　　種",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"業務\n内容",null,null,"\n"]
[]
["訪問希望日\n（午前・午\n後に○印）",null,null,null,null,"第１\n希望",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日","（",null,null,"）","第２\n希望",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日","(",null,")"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"午前",null,null,null,null,null,"午後",null,null,null,null,null,null,null,null,null,null,null,"午前",null,null,null,null,"午後"]
[]
["　※　希望する支援内容に☑を入れてください。"]
["産業保健総合支援センター",null,1,"専門的な相談対応と個別訪問支援"]
[null,null,null,null,"産業保健スタッフ等の方からの相談（専門スタッフがお答えします。）"]
[null,null,null,null,"作業環境管理、作業管理等について必要に応じて事業場を訪問しアドバイス"]
[null,null,null,null,"中小規模事業所を訪問し、メンタルヘルス対策の導入をお手伝い"]
[null,null,null,null,"管理監督者などを対象としたメンタルヘルス教育（ストレスチェック制度含む）"]
[null,null,null,null,"ストレスチェック制度の導入に関する支援"]
[null,null,2,"産業保健スタッフ等への研修会の実施"]
[null,null,null,null,"産業保健スタッフ等を対象として、専門的・実践的な研修"]
[null,null,null,null,"事業者や労働者の方を対象として、労働者の健康管理などに関する啓発セミナーの実施"]
["地域産業保健センター",null,"◎労働者５０人未満の小規模事業場の事業者や労働者の方を対象とします。"]
[null,null,1,"相談対応",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," ☆地域窓口のご案内\n ・東青地域産業保健センター\n ・弘前・黒石地域産業保健センター\n ・八戸地域産業保健センター\n ・五所川原地域産業保健センター\n ・十和田・三沢地域産業保健センター\n ・むつ下北地域産業保健センター"]
[null,null,null,null,"労働者の健康管理（メンタルヘルスを含む）"]
[null,null,null,null,"健康診断の結果について、医師からの意見陳述"]
[null,null,null,null,"長時間労働者、高ストレス者に対する面接指導"]
[null,null,2,"個別訪問による産業保健指導"]
[null,null,null,null,"事業場を訪問して、職場巡視、相談対応、労働衛生啓発事業の実施など、事業場の状況を\n踏まえた産業保健に係る指導"]
[]
["　希望する支援の具体的内容　※上記希望事項に関する具体的な要望等をご記入下さい。"]
[null,"研修を希望される場合は、（研修内容、対象者、研修時間など）ご希望内容をご記入ください。"]
[null,"（申込み時点で相談員等と個別にお話をしている場合には、その旨ご記入下さい。）"]
[]
[]
[]
[]
[]
["センターを知ったきっかけ\n（該当に☑をして下さい）",null,null,null,null,null,null,null,null,null,null,"1　ホームページ",null,null,null,null,null,null,null,null,null,null,null,null,4,"　メールマガジン"]
[null,null,null,null,null,null,null,null,null,null,null,"２　新聞・テレビ",null,null,null,null,null,null,null,null,null,null,null,null,5,"　労働基準監督署からの紹介"]
[null,null,null,null,null,null,null,null,null,null,null,"３　各団体の会合・説明会等",null,null,null,null,null,null,null,null,null,null,null,null,6,"　その他（　　　　　　　　　 　　　）"]
["注）　本申込書を、ＦＡＸまたはメールで送信してください。",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,null,null,null,null,null,"R1.11改"]