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["榆阳区煤炭公司职工病休假证明表"]
["姓  名",null,"性 别",null,"出生年月",null,"本人近期            二寸彩照          （加盖公司骑缝章）"]
["身份证号码",{"$nulls":3},"参加工作时间"]
["联系电话",{"$nulls":3},"门诊号       （住院号）"]
["诊断及   治疗意见   （写明离岗治疗和休养的时间）"," 诊断及治疗意见："]
[null," 主治医师（已取得执业医师资格证）签名："]
[null,"                                                        年    月    日"]
["科主任    意  见"," 意见："]
[null," 科主任签名：                                       科室盖章"]
[null,"                                                      年     月    日"]
["主管院长   意    见"," 意见："]
[null," 院长签名：                                         医院盖章"]
[null,"                                                       年     月    日"]
["    注：1、因重大疾病申请住院病假或大病休养假的职工、连续请病假超过两个月以及一年内累计请病假时间满两个月且需要继续请假的职工，请病假时应出具此表，同时须附医院的诊断证明、治疗意见和住院发票；"]
["        2、本表由公司核对本人与身份证、照片一致后在照片上加盖骑缝章，并粘贴身份证复印件，医院签字盖章后交公司考勤管理部门备案。"]

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