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["様式1"]
[{"$nulls":18},"受付番号"]
[null,"臨　床　研　究　施　設　利　用　報　告　書"]
["　　",{"$nulls":16},"　",null,null,"年",null,null,"月",null,null,"日"]
["静岡県立大学臨床研究センター附属臨床研究施設運営委員会委員長　殿"]
["                                 （申請者）＊研究代表者"]
[{"$nulls":7},"所属・職名"]
[{"$nulls":7},"氏　　　名",{"$nulls":17},"印"]
[]
["研究倫理審査\n委員会",{"$nulls":4},"受付番号",{"$nulls":24}," "]
[{"$nulls":5},"承認番号"]
["研究　　課題名"]
["共同   研究者　氏名",null,null,"※共同研究者の氏名（臨床研究施設運営委員会委員等である医師の氏名を記入願います。）"]
["実際に\n利用した　　日時",null,null,null,"年",null,"月",null,"日",null,null,"時",null,"分　","～",null,"時　",null,"分","利用スペース",null,null,null,"ＡＢＣＤ"]
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[{"$nulls":4},"年",null,"月",null,"日",null,null,"時",null,"分　","～",null,"時　",null,"分","利用スペース",null,null,null,"ＡＢＣＤ"]
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["事故・有害事象等の有無　（　　有　　・　　無　　）"]
["（有の場合、その内容、対処を簡潔に記載してください）"]
["その他特記事項"]
[]
["※委員会記入欄\n"]
["注１：",null,"申請書に記載いただきました内容については，施設運営のため連絡に使用する以外には、"]
["　",null,"一切使用いたしません。"]
["注２：",null,"事故・有害事象等が発生した場合、事故等報告書式も併せて提出してください。"]
["注３：",null,"利用日時欄が不足する場合は、別紙にすべての利用期間を記入して添付してください。"]