体健检资料搜集同意书.doc

校部新生體檢資料蒐集同意書 National Cheng Kung University for Freshman Physical Examination Consent for Release of Information 為符合「學生健康檢查實施辦法」、「外國人停留居留及永久居留辦法」, 同意國立成功大學醫學院附設醫院逕將本人之個人資料及體檢報告提供國立成功大學「衛生保健組」、與國立成功大學附設醫院家庭醫學部做為學生健康管理及辦理勞工健康管理業務之用。 In accordance with relevant laws and regulations of the “Health Examinations implementation measure” and “Governing Alien visits, Residence and Permanent Residence”; I, _________________________ (Name on your Passport), give my permission for National Cheng Kung University Hospital (NCKUH) to disclose my personal health information to the National Cheng Kung University (NCKU) Health Center and the NCKUH family medicine department for managing student health and labor safety and health related matters. □同意 新生體檢報告提供給國立成功大學?環境保護暨安全衛生中心?，以利本人於5年內(依體檢日開始計算)擔任國立成功大學之臨時工、工讀生、教學行政助理、兼任助理...等職之申請，無需另繳體檢報告。 □ Agree Would you agree to allow the Environmental Health and Security Center keep your personal health record for 5 years? If you agree, when you are applying for employment in NCKU, you don’t have to retake the physical examination and resubmit the report; as long as you have valid health record (within 5 years, from the date your personal health record was issued.) 敬致 (Sincerely,) 國立成功大學 (National Cheng Kung University) 國立成功大學醫學院附設醫院 (National Cheng Kung University Hospital) 同意人簽章Signature (Signature of Patient)：　　　 　　　　　　 身分證字號/護照號碼ARC No. / Passport No.：　　　 　　 　　　　 法定代理人Signature of Legal Representative： 法定代理人與病人關係Relation (Relationship to Patient)： 連絡電話Cellphone No.：(Contact Phone No.)　　　　　　 　　　 日期Date：　　　　年yyyy　　　月mm　　　日dd校部新生體檢資料蒐集同意書 National Cheng Kung University for Freshman Physical Examination Consent for Release of Information 為符合「學生健康檢查實施辦法」、「外國人停留居留及永久居留辦法」, 同意國立成功大學醫學院附設醫院逕將本人之個人資料及體檢報告提供國立成功大學「衛生保健組」、與國立成功大學附設醫院家庭醫學部做為學生健康管理及辦理勞工健康管理業務之用。 In accordance with relevant laws and regulations of the “Health Examinations implementation measure” and “G