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["劳 动 能 力 鉴 定 申 请 表"]
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[null,"工伤认定决定书编号："]
[null,"证件类型",null,"居民身份证",null,"□",null,"其他□"]
[null,"身份证件号码□□□□□□□□□□□□□□□□□□"]
[null,"联系电话（必填一项）：            （手机）             （固话）"]
[null,"联系地址:"]
[{"$nulls":7},"邮编□□□□□□"]
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[null,"联系地址:"]
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[null,"□1.初次鉴定；      □2.再次鉴定；     □3.复查鉴定；"]
[null,"□4.配置辅助器具确认，申请配置项目                      ；□5.其他"]
[null,"申请主体（请在□内打√单项选择）      "]
[null,"□1.用人单位； □2.工伤职工或者其近亲属； □3.社会保险经办机构。\n"]
[null,"申请人签名或者盖章 ：    ",null,null,null,"申请单位盖章 ：    "]
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[null,"劳动能力鉴定（结论）表"]
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[null,"伤情介绍："]
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[null,"鉴定依据："]
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[null,"专家组意见：","_________________________________________________________。"]
["1. 劳动功能障碍程度   经鉴定符合伤残                 级；"]
["2. 生活自理障碍程度   经鉴定符合               护理依赖；"]
[null,"a)进食；      □        ",null,null,null,"d)穿衣、洗漱；  □"]
[null,"b)翻身；      □       ",null,null,null,"e)自主行动。    □"]
[null,"c)大、小便 ； □"]
["3. 配置辅助器具确认   经鉴定                            。"]
["鉴定专家签名及意见：                                         。"]
[null,"专家1：",null,null,null,"专家4："]
[null,"专家2：",null,null,null,"专家5："]
[null,"专家3："]
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["劳动能力鉴定委员会结论："]
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["经审定，符合：\n                               级伤残；\n                             护理依赖；\n  配置辅助器具确认                       。"]
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["审核人签名(印章）：                                             年   月   日 "]
[]
[]
[]
[]
[null,"(注：本页劳动能力鉴定委员会留存)"]
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["    附件2"]
["初 次（复 查）鉴 定 结 论 书"]
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[null,null,null,"省（自治区、直辖市）     市（区）劳鉴      年     号"]
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[]
[null,"被鉴定人                  "]
[null,"身份证号                            "]
[null,"居住地址                                 "]
[null,"用人单位                                 "]
[null,"伤残情况                                 "]
[]
[]
["    根据《劳动能力鉴定  职工工伤与职业病致残等级》国家标准 ，经劳动能力鉴定专家组鉴定，你目前的伤残情况，符合                               。"]
["    鉴定结论为                                         。"]
[]
["    对本鉴定结论不服的，可以自收到本鉴定结论书之日起15日内向     省（自治区、直辖市）劳动能力鉴定委员会申请再次鉴定。"]
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[{"$nulls":5},"X X X 劳动能力鉴定委员会"]
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["注：本鉴定结论书一式四份，工伤职工、用人单位、社会保险经办机构、劳动能力鉴定委员会各一份。"]
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[null,"附件3"]
["再 次 鉴 定 结 论 书"]
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[{"$nulls":4},"省（自治区、直辖市）   劳鉴      年     号"]
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[null,"被鉴定人                 "]
[null,"身份证号                           "]
[null,"居住地址                                "]
[null,"用人单位                                 "]
[null,"伤残情况                                 "]
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["    根据《劳动能力鉴定  职工工伤与职业病致残等级》国家标准，经劳动能力鉴定专家组鉴定，你目前的伤残情况，符合                               。"]
["    鉴定结论为                                         。"]
[]
["    本鉴定结论为最终结论。"]
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[null,"附件4"]
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[{"$nulls":7},"编号："]
["劳动能力鉴定材料收讫补正告知书(存根）"]
["                  ："]
["    你（单位）提出的      劳动能力（初次鉴定/再次鉴定/复查鉴定/配置辅助器具确认）申请已于       年    月    日收到，经审核，"]
[null,"□1. 材料完整，予以收讫；"]
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[null,"②",{"$nulls":5}," "]
[null,"③"]
[null,"特此告知，请于     年  月  日前补正。"]
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[{"$nulls":7},"编号："]
["劳动能力鉴定材料收讫补正告知书"]
["                  ："]
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[null,"□1. 材料完整，予以收讫；"]
[null,"□2. 材料不完整,尚欠缺："]
[null,"①"]
[null,"②",{"$nulls":5}," "]
[null,"③"]
[null,"特此告知，请于     年  月  日前补正。"]
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[null,"联系电话（必填一项）：            （手机）             （固话）"]
[null,"现居住地址:"]
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[null,"□1、初次鉴定；   □2、复查鉴定；   □3、再次鉴定。\n\n"]
[null,"申请主体选择（请在□内打√单项选择）      "]
[null,"□1、用人单位申请；   □2、工伤职工或其近亲属申请。\n"]
[null,"申请人签名或盖章 ：    ",null,null,null,"用人单位印章 ：    "]
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