東海大學新進人員體格檢查紀錄表

新進人員填寫

個人資料保護法應告知事項Declaration to Collect, Process, and Use Personal Information

東海大學環境保護暨職業安全衛生中心（以下簡稱本中心）依據「個人資料保護法」第八條規定，取得您提供的個人健康資料，需告知下列事項並得到您的同意，請務必詳閱。若您未滿二十歲，應請您的法定代理人閱讀、瞭解並同意本同意書之所有內容。當您勾選「同意」並簽署本同意書時，表示您已閱讀、瞭解並同意接受本同意書之所有內容及其後修改變更規定。
一、蒐集之目的：依「勞工健康保護規則」及「職業安全衛生法」之相關規定，實施一般及特殊體格(健康)檢查，為落實及完善東海大學（以下簡稱本校）健康管理工作，以維護及促進師生健康。
二、蒐集之個人資料類別：
(一)個人基本資料：包含學號、就讀系所、工作單位、姓名、出生年月日、性別、身分證字號(或居留證號碼)、聯絡電話、電子信箱、保險類別、到職日期。
(二)基本健康資料：包含作業經歷、既往病史、自覺症狀、特殊疾病現況或應注意事項、家族病史等。
(三)生活習慣。
(四)自我健康評估。
(五)健康檢查項目包含：
1.理學檢查：身高、體重、腰圍、視力、辨色力、聽力、血壓及身體各系統或部位之理學檢查。
2.實驗室檢查：尿液、血液常規、血糖、血清丙胺酸轉胺酶(ALT)、肌酸酐(creatinine)、膽固醇、
三酸甘油酯、高密度脂蛋白膽固醇、低密度脂蛋白膽固醇之檢查。
3.胸部X光檢查（大片）。
4.其他經中央主管機關指定之檢查。
5.另應按其特別危害健康作業類別，依法所定之檢查實施特殊體格檢查。
三、個人資料利用之期間、地區、對象及方式：
(一)期間：就學及在職期間，並依「勞工健康保護規則」規定之報告保存期限。
(二)地區：台灣地區(包括澎湖、金門及馬祖等地區)或經師生授權處理、利用之地區
(二)對象：依法規定之主管相關單位。
(三)方式：合於法律規定之處理方式。
四、依據個資法第三條規定，您就本校保有您之個人資料得行使下列權利：
(一)查詢、請求閱覽或請求提供複製本。
(二)請求補充或更正，惟依法請您提出釋明。
(三)請求停止蒐集、處理或運用，並可請求刪除。(除依法規需保留部分）
五、您得自由選擇是否提供相關個人資料：
您可自由選擇是否提供個人資料，若您拒絕提供所需之個人資料或提供不完全時，本校將無法
為您提供完整之關懷與健康管理服務，尚祈見諒。
唯本校依個人資料保護法之規定保有准駁該申請之權，且因您行使上述權利，而導致權益受損時，本校將不負相關賠償責任。
The Center of Environmental Protection and Occupational Safety & Health of Tunghai University (hereafter the Center) is collecting your personal health information as is appropriately regulated in Article 8 of the Personal Data Protection Act. Please read the following carefully and grant us your approval. If you are under 20 of age, please have your legal representative read, understand, and agree on the content. Checking "agree" means you agree on the content of this form and modification.
I. Purpose of Collection: In accordance with the "Labor Health Protection Regulations" and the
"Occupational Safety and Health Act," general and special health examinations are implemented to improve the health management of Tunghai students and faculty.
II. Personal Data Categories.
(1) Basic personal information: including student/work number, department of study, workplace, name,
date of birth, gender, ID card number (or residence permit number), contact phone number, email address, type of insurance, and date of arrival.
(2) Basic health information: including career experience, past medical history, current symptoms,
special diseases or health precautions, hereditary medical history, etc.
(3) Daily Habits
(4) Self Health Evaluation
(5) Health Check Items:
i. Physical examination (parts or whole): height, weight, waist circumference, visual acuity, color discrimination, hearing, blood pressure, etc.
ii. Laboratory tests: urine, blood routine, blood glucose, serum prolaminotransferase (alt), creatinine, cholesterol. Triglycerides, HDL cholesterol, and LDL cholesterol.
iii. Chest x-ray (large film)
iv. Other examinations designated by the central authorities concerned.
v. Special physical examinations should be conducted according to the type of work that is particularly hazardous to health, as determined by law.
III. Period, area, target, and method of using personal information.
(1) Period: During the period of study and employment, and in accordance with the retention period of reports stipulated in the Labor-Health Protection Regulations.
(2) Area: Taiwan (including Penghu, Kinmen, and Matsu areas) or areas authorized for use by students and faculty.
(3) Target: The related units as stipulated by law.
(4) Method: In accordance with the legal provisions.
IV. In accordance with Article 3 of the Personal Data Protection Act, you may exercise the following rights with respect to your personal information held by the University.
(1) Inquiries, requests for access, or requests for copies.
(2) Request a supplement or correction, but you are required by law to provide an explanation.
(3) Request to stop collecting, processing, using, or deletion. (Except for the part required to be retained
by law)
V. You are free to choose whether or not to provide the relevant personal information.
You are free to choose whether or not to provide your personal information. However, if you refuse or provide incomplete information, the University will not be able to render full care and health management for you. The University reserves the right to deny the application in accordance with the provisions of the Personal Data Protection Act; if your rights are fringed as a result of your exercising such rights, the University will not be held liable.
個資聲明
The University has informed me of the above, and I understand clearly the purpose and use of my personal data as to how they are collected, processed, or used by the University. *

個資聲明
The University has informed me of the above, and I understand clearly the purpose and use of my personal data as to how they are collected, processed, or used by the University. 同意個資聲明 I have read and consented to the content of the form.
一、基本資料Basic Information
姓名Name *
身分證字號I.D. Number (or passport number) *
性別Gender *

性別Gender 男性 male 女性 female
出生日期（例：85 .01 .01 ）Date of Birth *
受僱日期 (例 : 85 . 01 .01 )Starting Date of Employment *
檢查日期 (例 :85 .01 .01 )Date of Health Examination *
工作單位Workplace *
連絡電話Contact Number *
電子信箱Email *
二、作業經歷Past Employment
曾經從事____.Used to work at/as *
起始日期：__年_ 月 ( 例 93. 02)Starting Date *
截止日期： __年__ 月 (例 100.02)Ending Date *
共__ 年__月 (例07.00)In total for ____ years ____ months *
目前從事____.Current Employment at/as *
起始日期：__年_ 月 (例 103.06)Starting Date
截止日期： __年__ 月(例 105.06)Ending Date
共__ 年__月 (例02.00)In total for ____ years ____ months
過去1個月，平均每週工時為:___ 小時
In the past 1 month, the average weekly working hours were: _____ hours *
過去6個月，平均每週工時為：___ 小時
In the past 6 months, the average weekly working hours were: _____ hours *
三、檢查時期（原因）Time of Health Check (Reason)

這是您的區域分隔說明文字
*
新進員工（受僱時） Recruit upon hiring 定期檢查 Regular health check
四、既往病史Medical History

這是您的區域分隔說明文字
您是否曾患有下列慢性疾病：（請在適當項目前打勾）
Did you have the following chronic diseases (please check) *
高血壓hypertension 糖尿病diabetes 心臟病 heart disease 白內障cataracts 中風stroke 癲癇epilepsy 氣喘asthma 慢性氣管炎、肺氣腫chronic bronchitis, emphysema 肺結核tuberculosis 腎臟病kidney disease 肝病liver disease 貧血 anemia 中耳炎Otitis media 聽力障礙Hearing impairment 甲狀腺疾病Thyroid disease 消化性潰瘍、胃炎Peptic ulcer, gastritis 逆流性食道炎Reflux esophagitis 骨折 Fracture 手術開刀Surgical operation 其他慢性病Other chronic diseases 以上皆無None of the above 癌症cancer ____ 癌症cancer ____
五、生活習慣Daily Habits

這是您的區域分隔說明文字
請問您過去一個月內是否有吸菸？Did you smoke in the past month *

請問您過去一個月內是否有吸菸？Did you smoke in the past month 從未吸菸Never 偶爾吸(不是天天)Sometimes (not every day) （幾乎）每天吸，平均每天吸___支(nearly) Every day: _____ cigarettes per day on the average for _____ years
續上題，已吸菸___年 *

如從未吸菸，請輸入"0"
已經戒菸，戒了__年__個月 (例 00.03)Already quit for _____ year(s) _____ months *

如從未吸菸，請輸入"0"
Enter "0" if never smoked
請問您最近六個月內是否有嚼食檳榔？Have you chewed betel nut in the last 6 months? *

請問您最近六個月內是否有嚼食檳榔？Have you chewed betel nut in the last 6 months? 從未嚼食檳榔Never chewed betel nut 偶爾嚼(不是天天)Occasionally (not daily) (幾乎）每天嚼，平均每天嚼____顆(nearly) Every day: _____ betel nuts per day on the average for _____ years
續上題，已嚼__年 *

如從未嚼檳榔，請輸入"0"
已經戒食，戒了__年__個月 (例 00.03) Already quit for _____ year(s) _____ months *

如從未嚼檳榔，請輸入"0"
請問您過去一個月內是否有喝酒？Did you drink wine in the past month? *

請問您過去一個月內是否有喝酒？Did you drink wine in the past month? 從未喝酒Never 偶爾喝(不是天天)Sometimes (not every day) （幾乎）每天喝，平均每週喝__次(nearly) Every day: _____ times per week on the average
最常喝____酒Most frequently what kind of wine: _____ *
續上題，每次___瓶 and (how many) _____ bottles each time? *
已經戒酒，戒了__年__個月 (例:03 年08 個月)Already quit for _____ year(s) _____ months *
請問您於工作日期間，平均每天睡眠時間為:___ 小時 How many hours do you sleep per day on average during the weekdays? _____ *
自覺症狀：您最近三個月是否常有下列症狀：（請在適當項目前打勾）
Self-perceived symptoms: Have you had any of the following symptoms in the last three months: (Please check the appropriate box) *
咳嗽cough 咳痰sputum 呼吸困難dyspnea 胸痛chest pain 心悸palpitations 頭暈dizziness 頭痛headache 耳鳴 tinnitus 倦怠lethargy 噁心nausea 腹痛abdominal pain 便秘constipation 腹瀉diarrhea 血便bloody stool 上背痛upper back pain 下背痛 lower back pain 手腳麻痛Numbness and pain in hands and feet 關節疼痛Pain in joints 排尿不適Discomfort in urination 多尿、頻尿Polyuria, frequent urination 手腳肌肉無力Muscle weakness in hands and feet 體重減輕3公斤以上Weight loss of more than 3 kg 其他症狀Other symptoms 以上皆無None of the above
重點說明:Important Notice:

1、請新進教職員同仁誠實填妥上表之基本資料、作業經歷、檢查時期、既往病史、生活習慣及自覺症狀六大項資料。
2、依職業安全衛生法第二十條規定雇主於僱用勞工時，應施行體格檢查；對在職勞工應施行下列健康檢查：
(1)一般健康檢查。
(2)從事特別危害健康作業者之特殊健康檢查。
(3)經中央主管機關指定為特定對象及特定項目之健康檢查。
3、依勞工健康保護規則第十四條規定雇主僱用勞工時，除應依附表八所定之檢查項目實施
一般體格檢查外，另應按其作業類別，依附表九所定之檢查項目實施特殊體格檢查。有
下列情形之一者，得免實施前項一般體格檢查：
(1)、非繼續性之臨時性或短期性工作，其工作期間在六個月以內。
(2)、其他法規已有體格或健康檢查之規定。
(3)、其他經中央主管機關指定公告。
本次體格檢查及後續各項健康檢查資料將提供本校做為職業安全與健康管理之重要參考資訊。
4、若無故不參與新進人員體格檢查者，依據職業安全衛生法第46條，將處於新臺幣3000元以下罰鍰。相關檢查紀錄，雇主應予保存7~30年。

＊本人已詳閱並了解相關說明，且所提供之相關資料皆屬事實。
1. New faculty members are requested to fill out the above form with basic information, career experience, examination period, medical history, living habits, and self-reported symptoms.
2. In accordance with Article 20 of the Occupational Safety and Health Law, employers shall conduct physical examinations when employing workers; the following health examinations shall be conducted for in-service workers.
(1) Regular Health Check
(2) Special health examination for those engaged in special health hazard operations.
(3) Designated by the central authority concerned as a specific target and specific items of health examination.
3. In accordance with Article 14 of the Labor-Health Protection Regulations, when an employer employs a worker, in addition to the inspection items outlined in the attached Table 8, the employer shall implement special physical examinations in accordance with the types of careers and the health check items outlined in Table 9. However, the following circumstances can be exempted from the preceding general physical examination.
(1) Temporary or short-term jobs not of a continuous nature and less than six months.
(2) Health examination requirements have been regulated elsewhere.
(3) Other announcements designated by the central authority concerned.
This physical examination and subsequent health examination data will provide the University with important reference information for occupational safety and health management.
4. Failing to participate in the medical examination for new employees without any reason will lead to a fine of up to NT$3,000 according to Article 46 of the Occupational Safety and Health Law. The employer shall keep the relevant examination records for 7~30 years.
* I have read and understood the relevant instructions and the information provided is factual.
請在下面方塊中畫出您的簽名Signature (please print) *

Clear
服務單位Service Unit *
日期 :中華民國__年__月__日(例87. 07.29)Date: ____ (Month) _____ (Date), _____ (Year) *

東海大學新進人員體格檢查紀錄表

東海大學新進人員體格檢查紀錄表

個人資料保護法應告知事項Declaration to Collect, Process, and Use Personal Information

一、基本資料Basic Information

二、作業經歷Past Employment

三、檢查時期（原因）Time of Health Check (Reason)

四、既往病史Medical History

五、生活習慣Daily Habits

重點說明:Important Notice: