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[{"$nulls":22},"提出日　　　年　　　月　　　日"]
["食物アレルギー提出用紙"]
[]
[null,"団　体　名"]
[]
[null,"担当者氏名",{"$nulls":6},"電話番号",{"$nulls":8},"・アレルギーがある方の記入表です。"]
[{"$nulls":17},"・食物の好き嫌いではありません。"]
[null,"利用日時",null,"年　　月　　日（　）　～　年　　月　　日（　）",{"$nulls":13},"・書ききれない場合は、コピーしてご利用ください。"]
[]
[]
["番号","氏名","小麦",null,null,null,"卵",null,null,null,"乳",{"$nulls":4},"落花生","エビ カニ",null,null,"魚・魚卵",null,null,"フルーツ","肉","その他"]
[]
[]
[null,null,"パン・麺等","　　　揚げ物のつなぎ等","【例】ウィンナー","原材料の一部","加熱したもの","　　　揚げ物のつなぎ等","【例】マヨネーズ","原材料の一部","生のもの【例】牛乳、チーズ等","加熱したもの【例】グラタン","　　　乳糖等","【例】ハム、ベーコン","原材料の一部","原材料の一部【例】カレー等","生のもの","加熱したもの","原材料の一部【例】エキス等","生のもの","加熱したもの","原材料の一部【例】エキス等","食べられない種類","食べられない種類","原材料名を記入"]
[{"$nulls":26},"必ずご記入ください"]
[]
[]
[]
[]
[{"$nulls":25},"対策をご記入ください"]
[]
[]
[]
["例","自然　太郎","×","○",null,null,"○","マヨネーズ×",null,null,"○","○","乳糖×",null,null,"○","×","○","○","×","○","○","メロン","鶏肉×","ゴマ","・自己（引率）判断で除去"]
[{"$nulls":22},"キウイ",null,null,"・自宅からの代替食を持参"]
["緊急ＴＥＬ","０００－００００－００００",{"$nulls":20},"×",null,null,"・代替食を希望　　等"]
[]
[]
["緊急ＴＥＬ"]
[]
[]
["緊急ＴＥＬ"]
[]
[]
["緊急ＴＥＬ"]
[]
[]
["緊急ＴＥＬ"]
[]
[]
["緊急ＴＥＬ"]