報名參加110學年度下學期教職員工一般體格及特殊體格(健康)檢查調查表Sign up for the general physical and special physical (health) examination questionnaire for the next semester of the 110 academic year

個人資料保護法應告知事項

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，學生是用本校新生健檢報告當做勞動部規定的新進人員之新進人員體格檢查，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。
Declaration to Collect, Process, and Use Personal Information
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.

填表說明：
一、 本學年度辦理之一般及特殊體格(健康)檢查對象：依據勞工健康保護規則第十五條規定，定期實施一般體格(健康)檢查：
(一)年滿65歲者，每年檢查一次。
(二)40歲以上未滿65歲者，每3年檢查一次。
(三)未滿40歲者，每5年檢查一次。
＊若無故不做健康檢查者，依據職業安全衛生法第46條，將處新臺幣三千元以下罰鍰。
特殊健康檢查：2類教職員工生一年需檢查一次。
*因本中心經費有限，符合學校健檢補助對象之同仁，請配合參加人事室安排醫院體檢專案，利用學校補助健檢經費做健康檢查。
學校補助對象有專任教職員工（含客座、講座、傑出校友講座）、約僱人員、軍訓教官、其他編制外專職人員（含推廣部、電算中心、募委會）及本校退休同仁。滿50歲同仁每學年補助一次；未滿50歲同仁每兩學年補助一次，補助金額以1500元為上限，金額低於1500元者以實際金額補助；請參考https://ithu.tw/77h，
基於學校經費不得重複核銷原則，即本中心舉辦之一般健康檢查與人事室通知之健檢專案，僅能二擇一。計畫人員與專案人員之一般健康檢查及此次全部人員特殊健康檢查經費由本中心支出。

二、 體（健）檢類別欄位請發交所屬相關作業之新進及在職教職員工生，依其實際作業類別勾選，例如：一般、高溫、噪音、游離輻射…等。
特殊體格（健康）檢查不得填報實際從事作業以外項目之檢查【例如：實際使用苯胺從事實驗，卻勾選聯苯胺特殊體格（健康）檢查】。

三、 敬請最近一年依實際從事特別危害健康作業(指有接觸化學品原料)情形勾選，若有相關問題請撥04-23590121轉30109或30103洽詢護理師。

Instructions for filling in the form:
1. Objects of general and special physical (health) examinations conducted this academic year: According to Article 15 of the Labor Health Protection Regulations, general physical (health) examinations shall be carried out regularly:
(1) Those who have reached the age of 65 shall be checked once a year.
(2) Those over the age of 40 and under the age of 65 shall be inspected every 3 years.
(3) Those under the age of 40 shall be inspected every 5 years.
＊If you fail to undergo a health check without a reason, you will be fined up to NT$3,000 in accordance with Article 46 of the Occupational Safety and Health Law.
Special health check: faculty and staff students need to be checked once a year.
*Due to the limited funding of this center, colleagues who are eligible for the school's health check-up subsidy, please cooperate with the personnel room to arrange the hospital's health check-up project, and use the school's subsidized health check-up funds to do the health check.
The target of school subsidy is full-time faculty and staff (including guest lecturers, lectures, outstanding alumni lectures), hired staff, military training instructors, other full-time staff outside the establishment (including promotion department, computer center, recruitment committee) and retired colleagues of the school. Colleagues over the age of 50 are subsidized once every academic year; colleagues under the age of 50 are subsidized every two academic years, the subsidy amount is up to 1,500 yuan, and those below 1,500 yuan are subsidized at the actual amount; please refer to https://ithu.tw/77h ,
Based on the principle that school funds cannot be written off repeatedly, that is, the general health checkups organized by the center and the health checkup projects notified by the personnel office can only choose one of the two. The general health checkup for planners and project personnel and the special health checkup for all personnel shall be paid by the center.

2. For the physical (health) examination category column, please send it to the new and in-service faculty and students of the relevant work, and tick it according to the actual work category, such as: general, high temperature, noise, ionizing radiation... etc.
Special physical (health) examinations are not allowed to fill in the examinations for items other than those actually engaged in operations [for example: actually use aniline to conduct experiments, but check the special physical (health) examination for benzidine].

3. Please tick according to the actual situation of special health hazard operations (referring to contact with chemical raw materials) in the past year. If you have any related questions, please dial 04-23590121 to 30109 or 30103 to consult a nurse.