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["_______ 縣（市）「115年度流感、COVID-19疫苗接種計畫」衛生等單位之防疫相關人員接種名冊"]
["接種對象類別：",null,"□衛生單位防疫人員 □各消防單位實際擔任救護車緊急救護工作之人員 □空中救護勤務人員"]
[null,null,"□第一線海巡、岸巡人員 □國際機場、港口入境安全檢查、證照查驗及第一線關務人員 "]
[null,null,"□法醫師 □具執業登記之公共衛生師"]
["機構/機關名稱：___________________________________________",{"$nulls":6},"負責人：______________"]
["地址：____________________________________________________",{"$nulls":6},"聯絡人：______________"]
["單位總人數：________",null,"擬接種人數：流感疫苗____人，COVID-19疫苗____人",{"$nulls":4},"電話：________________"]
[]
["編號","姓     名","出生年月日","身分證\n統一編號","接種意願(請勾選)",null,"編號","姓     名","出    生                年月日","身分證\n統一編號","接種意願(請勾選)"]
[{"$nulls":4},"流感疫苗","COVID-19\n疫苗",{"$nulls":4},"流感疫苗","COVID-19\n疫苗"]
{"$rows_empty":9}
["附註：","1.填寫本表前請勾選所屬接種對象類別。"]
[null,"2.具接種意願者填寫個人資料進行列冊。"]
[]
[{"$nulls":3},"填表機關核章____________________",{"$nulls":3},"執行接種之醫師及醫療院所核章__________________"]