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["研究検査依頼書",null,null,null,null,null,null,null,null,"別紙資料"]
[null,null,null,null,null,null,null,null,null,"整理No."]
["申込日",null,null,null,null,null,null,null,"提出者"]
["新規・変更",null,null,null,null,"変更届出日"]
["依頼科",null,null,null,null,"依頼科所属長",null,null,null,null,"連絡先"]
["期間"]
["研究および試験について"]
["試験及び\n研究名"]
["（治験）依頼者",null,null,null,null,null,null,"予定症例登録数"]
["依頼内容と\n頻度"]
["依頼の具体的流れと方法（依頼者）"]
["検査の目的"]
["具体的な\n流れと方法",null,"※材料、及び検査部で実施する受取り～受渡しまでの作業を簡潔に記載してください。"]
[]
[]
["その他注意事項（依頼者）"]
[]
["作業時間・条件など（検査部回答）"]
[]
[]
["責任者会議承認日",null,null,"年　　月　　日",null,null,null,"検査部長",null,null,"検査技師長"]
["回覧","要・不要",null,"回答日","年　　月　　日"]
["※途中変更が生じた場合は再度「依頼書」と「変更概要」を提出"]

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["研究および試験について"]
["試験及び\n研究名"]
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["依頼内容と\n頻度"]
["変更概要（依頼者）"]
["変更点",null,"※変更の概要を箇条書きで記載してください"]