ち          ゆ       ほう           こく    しょ
                                                                                   治 癒 報 告 書
                                                                                                                                                           令和               年              月             日
      千葉県立船橋高等学校長 様
 
 
                                                                                                                                                                年                     組                    番
                                                                                                                               せ い と し め い
                                                                                                                               生徒¹氏名
 
                                                                                                                               ほ    ご   しゃ   し めい
                                                                                                                               保護者氏名
 
          い     し         しんだん           か   き し っかん                                  ち   ゆ        ほか     かんせん                                     とうこう       さしつか
      医師が診断した下記疾患について、ほぼ治癒し他に感染のおそれはなく登校に差支えないこと
 
      ほうこく
 を報告いたします。
 
                                                                                                            き
                                                                                                            記
 
 し っ かん め い                                       し っかん
 疾 患 名（あてはまる疾患に○をつける）
 
 
          しんがた                                        かんせんしょう                                                             かた                  すいとう                は し か             ふうしん
      新 型 コロナウイルス感 染 症                                          ・     インフルエンザ（                                  型）          ・      水痘          ・       麻疹 ・               風疹               ・
 
     ひゃくにち ぜ き                  りゅうこうせい じ か せ ん え ん             りゅうこうせい か く け つ ま く え ん           か ん せ ん せ い い ちょうえん               よ う れ ん き ん かんせんしょう
     百日咳 ・ 流行性耳下腺炎 ・ 流行性角結膜炎 ・ 感染性胃腸炎 ・ 溶連菌感染症 ・
 
                                       かんせんしょう                  た
    マイコプラズマ感染症 ・ その他（                                                                                                                                                                                  ）
 
   しん        だん   び
 診 断 日                                           令和                    年             月                    日
 
 りょうよう き か ん
 療養期間                                           令和                    年             月                    日  令和                                  年                 月                 日 まで
 
 じゅしん                  びょういんめい                                                                                                  びょういん し ょ ざ い ち                                   し
 受診した 病 院名                                                                                                                         （病院 所在地                                               市）
 
 
 
      【担任記入欄】
      1 出席簿上の出席停止期間
 
                      令和                  年                月            日（           ）          限  令和                                  年             月            日（               ）           限
 
                      令和                  年                月            日（           ）          限  令和                                  年             月            日（               ）           限
 
                      出席停止日数¹                                   日間
      2 受診日等確認（いずれかに）                                                       □電話                  □領収書（診療明細書）                                    □その他
 
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