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["苏州市工伤职工康复治疗申请表"]
[{"$nulls":5},"　工伤康复编号："]
["申请人：","用人单位□　　个人□",{"$nulls":4},"　　　区属："]
["单位名称",{"$nulls":5},"单位社保编号",null,"一寸\n照片"]
["单位地址"]
["联系人",null,"联系电话",{"$nulls":8}," "]
["职工姓名",null,"性别",null,"年龄",null,"个人社保编号"]
["身份证号",{"$nulls":5},"个人联系电话"]
["家庭住址",{"$nulls":5},"参保情况","是□　 否□"]
["工伤认定书编号",{"$nulls":5},"康复记录","首次□再次□"]
["事故类别",null,null,"受伤时间(职业病诊断时间)"]
["诊断医院",{"$nulls":5},"现住医院"]
["诊断结果"]
["受伤害及住院治疗情况"]
[]
[{"$nulls":11},"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     "]
["工伤职工或\n亲属意见","\n\n\n签名：                       年    月    日"]
[]
[]
["用人单位\n意见","\n\n\n签名（盖章）：                    年    月    日"]
[]
[]
["工伤认定部门\n初审意见","\n\n\n签名（盖章）：                    年    月    日"]
[]
[]
["工伤康复机构\n审批意见","\n\n\n签名（盖章）：                    年    月    日"]
[]
[]
["说明：\n　　1、本表由单位或工伤职工填写。\n    2、申请人持工伤认定书、身份证复印件、本表到经办机构审批。\n    3、与原工伤单位依法解除或终止劳动关系的工伤职工，不再进行康复对象确认。\n　"]