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[]
["___________ 縣（市）「115年度流感疫苗接種計畫」執業登記醫事人員及"]
["醫療院所非醫事人員擬接種人數統計表"]
[{"$nulls":8},"填表日期____年____月____日",{"$nulls":3},"           共      頁，第     頁"]
["鄉鎮                      市區","醫療\n（事）機構名稱","醫院\n層級別","合計\n總人數","接種對象",{"$nulls":7},"備註"]
[{"$nulls":4},"執業登記醫事人員",null,"編制內非醫事人員",null,"實習學生",null,"衛生保健志工",null,"是否具有疫苗領取及存放冷藏設備","是否具有自行接種能力"]
[{"$nulls":4},"總人數","擬接種\n人數","總人數","擬接種\n人數","總人數","擬接種\n人數","總人數","擬接種\n人數"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
[{"$nulls":12},"□是    □否","□是    □否"]
["合      計"]
[]
[null,null,"填表人簽名或核章______________________",{"$nulls":5},"覆核人簽名或核章______________________"]