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["本 人 情 報","氏 名",null,null,null,null,null,null,null,null,"フリガナ",null,null,null,null,null,null,null,null,"【地図・避難経路・避難方法などの注意すべき事項など】",null,null,null,null,null,null,null,null,null,null,null,null,"地図は別紙"]
[null,"生年月日(満年齢)",null,"年 　月 　日（　　才）",null,null,null,null,null,null,"性 別",null,null,null,null,null,null,null,null,null,null,null,"避難時に世帯構成員が帯同する",null,null,null,null,null,null,"帯同する世帯構成員（",null,null,null,null,null,"）"]
[null,"住 所",null,null,null,null,null,null,null,null,"電 話(FAX)"]
[null,"認定等",null,null,"高齢者に該当する",null,null,null,"【　独　居 ・ 75歳以上のみ世帯 ・ 昼間独居　】"]
[null,null,null,null,"介護保険の認定を受けている",null,null,null,null,null,"【要支援１･２要介護１･２･３･４･５】"]
[null,null,null,null,"身体障害者手帳を持っている",null,null,null,null,null,"【身体障がい１･２･３･４･５･６･７】"]
[null,null,null,null,"療育手帳を持っている",null,null,null,null,null,"【療育Ａ　・　療育Ｂ】"]
[null,null,null,null,"精神保健福祉手帳を持っている",null,null,null,null,null,"【精神障がい１・２・３・４・５】"]
[null,"災害時に\n配慮すべき\n事項",null,null,"１　移動の動作を自分ですることができない、または難しい"]
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[null,"本人と\n構成員の関係",null,null,null,null,null,null,null,null,null,null,null,"ペットの数",null,null,null,"匹",null,null,"排せつ（",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,"ペットの避難",null,null,"希望する",null,null,null,"移動（",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,"コミュニケーション（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
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[null,"氏名(団体名)",null,null,null,null,null,null,null,null,"メール"]
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["緊急連絡先","フリガナ",null,null,null,null,null,null,null,"連絡先等","電話(FAX)"]
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[]
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[null,"氏名(団体名)",null,null,null,null,null,null,null,null,"メール"]
[null,"住所",null,null,null,null,null,null,null,null,"本人との関係",null,null,null,null,null,null,null,"　以上の計画内容について確認し、大山町、支援者および地域支援者で共有することに同意します。"]
["支援者","フリガナ",null,null,null,null,null,null,null,"連絡先等","電話(FAX)",null,null,null,null,null,null,null,"地域支援者（自治会(自主防災組織含む)・民生児童委員・大山消防署・琴浦大山警察署・大山町社会福祉協議会）"]
[null,"氏名(団体名)",null,null,null,null,null,null,null,null,"メール"]
[null,"住所",null,null,null,null,null,null,null,null,"本人との関係",null,null,null,null,null,null,null,null,"計画同意確認日",null,null,"年　　月　　日",null,null,null,null,"同意者署名"]
["※ 支援者 … 実際に避難支援を行う人、かかりつけ医、利用中の介護や障がいの福祉サービス関係者など"]

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["本 人 情 報","氏 名",null,"大山　太郎",null,null,null,null,null,null,"フリガナ",null,null,"ダイセン　タロウ",null,null,null,null,null,"【地図・避難経路・避難方法などの注意すべき事項など】",null,null,null,null,null,null,null,null,null,null,null,null,"地図は別紙"]
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[null,"認定等",null,null,"高齢者に該当する",null,null,null,"【 独　居 ・ 75歳以上のみ世帯 ・ 昼間独居 】",null,null,null,null,null,null,null,null,null,null,"・避難時は車いす"]
[null,null,null,null,"介護保険の認定を受けている",null,null,null,null,null,"【要支援１･２要介護１･２･３･４･５】",null,null,null,null,null,null,null,null,"・避難の際に必要なものは玄関に置いてある"]
[null,null,null,null,"身体障害者手帳を持っている",null,null,null,null,null,"【身体障がい１･２･３･４･５･６･７】",null,null,null,null,null,null,null,null,"　黄色のリュックに入っている"]
[null,null,null,null,"療育手帳を持っている",null,null,null,null,null,"【療育Ａ　・　療育Ｂ】"]
[null,null,null,null,"精神保健福祉手帳を持っている",null,null,null,null,null,"【精神障がい１・２・３・４・５】"]
[null,"災害時に\n配慮すべき\n事項",null,null,"１　移動の動作を自分ですることができない、または難しい"]
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[null,"本人と\n構成員の関係",null,null,null,null,null,null,null,null,null,null,null,"ペットの数",null,1,null,"匹",null,null,"排せつ（",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,"ペットの避難",null,null,"希望する",null,null,null,"移動（",null,null,"普段は杖をついて移動",null,null,null,null,null,null,null,null,null,null,null,"）"]
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[null,"氏名(団体名)",null,"大山　愛",null,null,null,null,null,null,"メール",null,null,"なし"]
[null,"住所",null,"大山町御来屋467-1",null,null,null,null,null,null,"本人との関係",null,null,"長女",null,null,null,null,"特記事項","【その他利用中のサービス、留意事項等】"]
["緊急連絡先","フリガナ",null,"ダイセン　ダイスケ",null,null,null,null,null,"連絡先等","電話(FAX)",null,null,"080-0000-0000",null,null,null,null,null,"デイサービス大山　毎週：火曜日　9：00～16：00"]
[null,"氏名(団体名)",null,"大山　大輔",null,null,null,null,null,null,"メール",null,null,"daisuke123@daisen.ne.jp"]
[null,"住所",null,"米子市△△1丁目11-1",null,null,null,null,null,null,"本人との関係",null,null,"長男"]
[]
["支援者","フリガナ",null,"ナワ　イチロウ",null,null,null,null,null,"連絡先等","電話(FAX)",null,null,"090-1111-2222",null,null,null,null,null,"＜作成日＞",null,"令和 7年 4月 15日"]
[null,"氏名(団体名)",null,"名和　一郎",null,null,null,null,null,null,"メール",null,null,"なし"]
[null,"住所",null,"大山町御来屋467-〇",null,null,null,null,null,null,"本人との関係",null,null,"自主防災組織",null,null,null,null," 以上の計画内容について確認し、大山町、支援者および地域支援者で共有することに同意します。"]
["支援者","フリガナ",null,"デイサービスダイセン　ナカヤマハナコ",null,null,null,null,null,"連絡先等","電話(FAX)",null,null,"0859-00-6789",null,null,null,null,"地域支援者（自治会(自主防災組織含む)・民生児童委員・大山消防署・琴浦大山警察署・大山町社会福祉協議会）"]
[null,"氏名(団体名)",null,"デイサービス大山　中山花子",null,null,null,null,null,null,"メール",null,null,"day-daisen@dayd.co.jp"]
[null,"住所",null,"大山町◇◇123",null,null,null,null,null,null,"本人との関係",null,null,"通所介護担当者",null,null,null,null,null,"計画同意確認日",null,null,"令和 7年 4月 15日",null,null,null,null,"同意者署名",null,"　大山　太郎"]
["※ 支援者 … 実際に避難支援を行う人、かかりつけ医、利用中の介護や障がいの福祉サービス関係者など"]