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["附件22"]
["确认项目申请表"]
["申请人：",null,"时间：",null,null,"登记号："]
["姓名",null,"性别",null,"出生年月日",null,"照片"]
["身份证号码"]
["家庭详细住址"]
["邮政编码",null,"联系电话"]
["用人单位"]
["单位详细地址"]
["邮政编码",null,"单位联系人",null,null,"联系电话"]
["受伤时间",null,null,"工伤认定结论编号"]
["伤残等级",null,null,"鉴定结论编号"]
["申请确认项目："]
["  □    (一)停工留薪期的确认； \n  □    (二)停工留薪期满后仍需继续治疗的确认；\n  □    (三)工伤直接导致疾病的确认；\n  □    (四)康复性治疗的确认；\n  □    (五)旧伤复发的确认； \n  □    (六)配置辅助器具的确认。"]
["注：1、用钢笔或签字笔填写，字体工整清楚。\n    2、申请人为用人单位，须在申请人处加盖单位公章。\n    3、登记号由受理的劳动能力鉴定委员会填写。\n    4、申请(一)和(二)项确认时，伤残等级和鉴定结论编号栏不需要填写。\n    5、须申请确认的项目，请在该项目名称前的□中打√。每次只可选择一项。\n    6、申请鉴定应提交下列材料：\n       a.工伤认定结论的复印件；b.工伤医疗的病历、检查化验单等有关资料；\n       c.身份证复印件。\n    7、鉴定受理地点：                               \n       联系电话："]