漢生病檢查 / Examinations for Hansen s Disease 全身皮膚視診結果 / Skin Examination 正常 / Normal 異常 / Abnormal 非漢生病 / Not related to Hansen s disease 疑似漢生病須進一步檢查 / H

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1 醫院標誌 Hospital s Logo 居留或定居健康檢查項目表 Health Certificate for Residence Application ( 醫院名稱地址電話傳真 ) (Hospital s Name, Address, Tel, Fax) 檢查日期 / Date of Examination YYYY / MM / DD 姓名 Name 身份證字號 ID No. 出生年月日 YYYY / MM / DD Date of Birth 年齡 Age 基本資料 / Basic Data 性別男 / M 女 / F Sex 護照號碼 Passport No. 國籍 Nationality 聯絡電話 Phone No. 照片 / Photo 實驗室檢查 / Laboratory Examinations A. 胸部 X 光肺結核檢查 / Chest X-ray for Tuberculosis X 光發現 / Findings 判定 / Result 合格 / Passed 疑似肺結核 / TB suspect 無法確認診斷 / Pending 不合格 / Failed 孕婦或 12 歲以下兒童免驗 / Not required for pregnant women or children under 12 years of age B. 腸內寄生蟲糞便檢查 / Stool Examination for Parasites 陽性, 種名 / Positive, Species 陰性 / Negative 其他可不予治療之腸內寄生蟲 / Other parasites that do not require treatment 來自附錄三之國家 / 地區者免驗 / Not required for applicants from countries/areas listed in Appendix 3 C. 梅毒血清檢查 / Serological Tests for Syphilis 檢驗 / Tests a. RPR VDRL 陽性 / Positive, 效價 / Titers 陰性 / Negative, 效價 / Titers b. TPHA TPPA FTA-abs TPLA EIA CIA 陽性 / Positive, 效價 / Titers 陰性 / Negative, 效價 / Titers c. other 陽性 / Positive, 效價 / Titers 陰性 / Negative, 效價 / Titers 判定 / Result 合格 / Passed 不合格 / Failed 15 歲以下兒童免驗 / Not required for children under 15 years of age D. 麻疹及德國麻疹之抗體陽性檢查報告或預防接種證明 / Proof of Positive Measles and Rubella Antibody or Measles and Rubella Vaccination Certificates a. 抗體檢查 / Antibody Tests 麻疹抗體 / Measles Antibody 陽性 / Positive 陰性 / Negative 未確定 / Equivocal 德國麻疹抗體 / Rubella Antibody 陽性 / Positive 陰性 / Negative 未確定 / Equivocal b. 預防接種證明 / Vaccination Certificates ( 證明應包含接種日期接種院所及疫苗批號 ; 接種日期與出國日期應至少間隔兩週 / The certificate should include the date of vaccination, the name of administering hospital or clinic and the batch no. of vaccine; the date of vaccination should be at least two weeks prior to traveling overseas.) 麻疹預防接種證明 / Measles Vaccination Certificate 德國麻疹預防接種證明 / Rubella Vaccination Certificate c. 有接種禁忌, 暫不適宜預防接種 / Having contraindications, not suitable for vaccination

2 漢生病檢查 / Examinations for Hansen s Disease 全身皮膚視診結果 / Skin Examination 正常 / Normal 異常 / Abnormal 非漢生病 / Not related to Hansen s disease 疑似漢生病須進一步檢查 / Hansen s disease suspect who needs further examinations a. 病理切片 / Skin Biopsy b. 皮膚抹片 / Skin Smear 陽性 / Positive 陰性 / Negative c. 皮膚病灶合併感覺喪失或神經腫大 / Skin lesions combined with sensory loss or enlargement of peripheral nerves 有 / Yes 無 / No 判定 / Result 合格 / Passed 須進一步檢查 / Needs further examinations 不合格 / Failed 來自附錄四之國家 / 地區者免驗 / Not required for applicants from countries/areas listed in Appendix 4 健康檢查總結果 / The final result of health examination 合格 / Passed 須進一步檢查 / Need further examinations 不合格 / Failed 負責醫檢師簽章 / Signature of Chief Medical Technologist 負責醫師簽章 / Signature of Chief Physician 醫院負責人簽章 / Signature of Superintendent 日期 / DateYYYY / MM / DD 備註 / Note 本證明三個月內有效 / The certificate is valid for three months.

3 附錄一愛滋篩檢與治療費用通知書 ( 請健檢醫院將此通知書併同健康檢查證明發給受檢者 ) 一中華民國政府已修改法規, 取消非本國籍人類免疫缺乏病毒 (HIV) 感染者之入境停留及居留限制, 也取消此項健康檢查項目二由於非本國籍人士在中華民國治療 HIV 感染之費用, 中華民國政府不提供補助, 每年治療費用約為新臺幣三十萬元 ( 約美金一萬元 ), 建議非本國籍人士先於母國接受 HIV 篩檢, 了解自身健康狀況 ; 如為 HIV 感染者, 建議留在母國接受治療欲來中華民國工作者, 請先行購買醫療保險, 以免造成個人財務負擔三外籍人士進入中華民國後, 可自行至醫院進行 HIV 篩檢, 了解自身感染狀況, 傳染病諮詢電話為 Appendix 1 Notice for HIV Screening and Treatment Costs (Health examination hospitals shall issue this notice and health certificate to the examinee) 1. The Government of Republic of China (Taiwan) has revised its laws to lift restrictions on entry, stay and residence of non-roc nationals infected with human immunodeficiency virus (HIV) in addition to removing this item from health examination. 2. The Government of Republic of China (Taiwan) does not offer subsidies to non-roc nationals infected with HIV infection for treatment in Taiwan. The annual treatment costs for HIV is NTD$300,000 (approximately USD$10,000). It is strongly advised that non-roc nationals to undergo HIV screening in their homeland prior to visiting Taiwan in order to understand their own health conditions. Persons infected with HIV are strongly advised to stay in their homeland for treatment. Persons intending to work in Taiwan are advised to purchase medical health insurance in advance to avoid financial burdens. 3. Upon entry into the Republic of China (Taiwan), foreigners may undergo HIV screening at a hospital to determine their infection status. The consultation hotline for infectious diseases is Phụ lục 1 Giấy thông báo chi phí xét nghiệm và điều trị HIV (Đề nghị bệnh viện khi cấp Báo cáo khám sức khỏe thì cấp kèm Giấy thông báo này) 1. Chính phủ Đài Loan đã sửa đổi pháp lệnh, hủy bỏ quy định hạn chế nhập cảnh, tạm trú và cư trú đối với người nước ngoài bị Hội chứng suy giảm miễn dịch mắc phải (HIV), và cũng hủy bỏ hạng mục xét nghiệm này trong quy định khám sức khỏe. 2. Do Chính phủ Đài Loan không trợ cấp chi phí điều trị HIV tại Đài Loan cho người nước ngoài, mà chi phí điều trị mỗi năm khoảng 300 ngàn Đài tệ (khoảng 10 ngàn Đô la Mỹ), nên kiến nghị người nước ngoài, trước khi đến Đài Loan hãy tiến hành xét nghiệm HIV ở nước mình để nắm bắt tình hình sức khỏe của bản thân; nếu bị nhiễm HIV, kiến nghị hãy ở lại nước mình để điều trị. Đối với người dự định đến Đài Loan làm việc, kiến nghị hãy mua Bảo hiểm Sức khỏe trước, nhằm tránh gánh nặng tài chính cho bản thân. 3. Người nước ngoài sau khi đến Đài Loan có thể tự đến bệnh viện xét nghiệm HIV để nắm bắt tình hình nhiễm bệnh của mình, số điện thoại tư vấn bệnh truyền nhiễm tại địa bàn Đài Loan là

4 ภาคผนวก 1 ใบแจ งค าใช จ ายในการตรวจและร กษาโรคเอดส (ให โรงพยาบาลท ร บการตรวจแนบใบแจ งน พร อมก บใบตรวจส ขภาพให ก บเจ าต ว) 1. ร ฐบาลไต หว นได ยกเล กค าส งการห ามชาวต างชาต ท ต ดโรคเอดส (HIV) เข าประเทศ หย ดแวะและอย อาศ ยในไต หว น รวมท งการตรวจส ขภาพในรายการน ด วย 2. เน องจากร ฐบาลไต หว นไม ออกค าใช จ ายในการตรวจและร กษาโรคเอดส ให ก บบ คคลท ไม ใช ส ญชาต ไต หว น ค าร กษาพยาบาลโรคเอดส ตกประมาณป ละ NT$ 300,000 (หร อประมาณ US$ 10,000) จ งขอแนะน าชาวต างชาต ให ตรวจโรคเอดส (HIV) ในประเทศของตนก อนเด นทางมาไต หว น หากป วยเป นโรคเอดส ให ร บการร กษาในประเทศของตนเส ยก อน ผ ท ประสงค จะมาท างานในไต หว นให ซ อประก นการร กษาพยาบาลล วงหน า เพ อป องก นภาระท อาจเก ดข นในภายหล ง 3. ชาวต างชาต เม อเด นทางเข ามาไต หว นสามารถขอตรวจโรคเอดส (HIV) จากโรงพยาบาลได ด วยตนเอง เพ อร บร สภาพร างกายตนเอง หร อต ดต อสอบถามได ท ศ นย ให ค าปร กษาโรคต ดต อ Lampiran 1 Surat Pemberitahuan Seleksi AIDS dan Biaya Pengobatan (Mohon rumah sakit yang mengadakan pemeriksaan menyampaikan surat pemberitahuan ini beserta dengan surat keterangan pemeriksaan kesehatan kepada orang yang melakukan pemeriksaan) 1. Pemerintah Taiwan telah mengubah peraturan, dimana telah membatalkan non warga negara Taiwan yang terjangkit virus (HIV)masuk ke negara ini, menetap dalam jangka waktu pendek atau menetap dalam jangka waktu yang lama yang dibatasi waktunya dan juga telah membatalkan item ini dari pemeriksaan kesehatan. 2. Mengenai biaya pengobatan dari non warga negara Taiwan yang terjangkit virus (HIV)di Taiwan tidak ditanggung oleh pemerintah Taiwan lagi, pemerintah Taiwan tidak akan memberikan subsidi, setiap tahun biaya pengobatan kira-kira sebesar tiga ratus ribu NT$ ( kira-kira sepuluh ribu US $), sarankan sebelum non warga negara Taiwan datang ke Taiwan, terlebih dahulu mengadakan pemeriksaan HIV di negara asal, dan untuk mengetahui kondisi kesehatan badan sendiri ; bila telah terjangkit HIV, sarankan mengadakan pengobatan di negara asal terlebih dahulu. Bagi yang hendak bekerja di Taiwan mohon terlebih dahulu membeli asuransi pengobatan, demi untuk menghindari terjadinya beban keuangan secara pribadi. 3. Setelah pendatang asing masuk ke Taiwan, dapat melakukan pemeriksaan seleksi HIV ke rumah sakit dengan sendiri, demi untuk lebih jelas tentang kondisi terjangkit virus ini, boleh telpon ke nomor telepon konseling penyakit menular di wilayah Taiwan adalah

5 附錄二辦理居留或定居健康檢查補充說明事項 Appendix 2 Additional instructions of health examination for residence application 一 6 歲以下兒童免辦理健康檢查, 但須檢具預防接種證明備查 ( 年滿 1 歲以上者, 至少接種 1 劑麻疹德國麻疹疫苗 ) Children under 6 years of age are exempt from health examination, but the certificate of vaccination is necessary. (Child age one and above should get at least one dose of measles and rubella vaccines). 二懷孕婦女及 12 歲以下兒童免驗胸部 X 光檢查 ; 懷孕婦女於產後應補辦理胸部 X 光檢查 Pregnant women and children under 12 years of age are exempt from chest X-ray examination; Pregnant women should undergo chest X-ray examination after the child s birth. 三得申請免驗胸部 X 光檢查之資格來自結核病盛行率低於十萬分之三十的國家, 並檢具由精神科醫師出具申請人在心理上不適合進行胸部 X 光檢查之診斷證明書, 經衛生福利部疾病管制署審核通過者, 始得免除此項檢查 Qualifications for applying exemption from chest X-ray examination People who are from countries with a tuberculosis prevalence rate of under 30/100,000 and who have received the physical examination certificate that deemed the individual as being unsuitable to undergo chest X-ray examination, which is verified by CDC, are exempt from the examination. 四腸道寄生蟲糞便檢查採離心濃縮法 Stool examination for parasites should be done with centrifugal concentration. 五 15 歲以下兒童免驗梅毒血清檢查 Children under 15 years of age are exempt from serological test for syphilis. 六漢生病檢查為全身皮膚檢查, 受檢者可穿著內衣內褲, 並由親友或女性醫護人員陪同受檢檢查時逐步分部位受檢, 避免一次脫光全身衣物, 維護受檢者隱私 Hansen s disease examination refers to careful examination of the entire body surface, which should be done with courtesy and respect to the applicant s privacy. During the examination, the applicant is allowed to wear underwear and be accompanied by a friend or female medical personnel. Hospitals or clinics have the responsibility to protect the privacy of the applicant, and the examination should be done step by step. Hence, taking off all clothes at the same time should be avoided.

6 附錄三免驗腸內寄生蟲糞便檢查之國家 / 地區表 Appendix 3 List of countries/areas not required to undergo stool examination for parasites 西太平洋區 Western Pacific Region 澳洲 Australia 汶萊 Brunei Darussalam 香港 Hong Kong 日本 Japan 澳門 Macao 紐西蘭 New Zealand 韓國 Republic of Korea 新加坡 Singapore 臺灣之無戶籍國民 nationals without registered permanent residence in Taiwan 東地中海區 Eastern Mediterranean Region 巴林 Bahrain 科威特 Kuwait 卡達 Qatar 沙烏地阿拉伯 Saudi Arabia 阿拉伯聯合大公國 United Arab Emirates 美洲區 Region of the Americas 阿根廷 Argentina 加拿大 Canada 智利 Chile 美國 United States of America 歐洲區 European Region 阿爾巴尼亞 Albania 安道爾 Andorra 亞美尼亞 Armenia 奧地利 Austria 白俄羅斯 Belarus 比利時 Belgium 波士尼亞與赫塞哥雅納 Bosnia and Herzegovina 保加利亞 Bulgaria 克羅埃西亞 Croatia 賽普勒斯 Cyprus 捷克 Czech Republic 丹麥 Denmark 愛沙尼亞 Estonia 芬蘭 Finland 法國 France 喬治亞 Georgia 德國 Germany 希臘 Greece 匈牙利 Hungary 冰島 Iceland 愛爾蘭 Ireland 以色列 Israel 義大利 Italy 哈薩克 Kazakhstan 拉脫維雅 Latvia 立陶宛 Lithuania 盧森堡 Luxembourg 馬爾他 Malta 摩納哥 Monaco 蒙特內哥羅 Montenegro 荷蘭 Netherlands 挪威 Norway 波蘭 Poland 葡萄牙 Portugal 摩爾多瓦 Republic of Moldova 羅馬尼亞 Romania 俄羅斯 Russian Federation 聖馬利諾 San Marino 塞爾維亞 Serbia 斯洛伐克 Slovakia 斯洛維尼亞 Slovenia 西班牙 Spain 瑞典 Sweden 瑞士 Switzerland 馬其頓 The former Yugoslav Republic of 土耳其 Turkey Macedonia 土庫曼 Turkmenistan 烏克蘭 Ukraine 英國 United Kingdom

7 附錄四免驗漢生病檢查之國家 / 地區表 Appendix 4 List of countries/areas not required to undergo examination for Hansen s disease 西太平洋區 Western Pacific Region 澳洲 Australia 香港 Hong Kong 澳門 Macao 汶萊 Brunei Darussalam 日本 Japan 紐西蘭 New Zealand 韓國 Republic of Korea 新加坡 Singapore 臺灣之無戶籍國民 nationals without registered permanent residence in Taiwan 美洲區 Region of the Americas 加拿大 Canada 美國 United States of America 歐洲區 European Region 阿爾巴尼亞 Albania 亞美尼亞 Armenia 白俄羅斯 Belarus 智利 Chile 安道爾 Andorra 奧地利 Austria 比利時 Belgium 波士尼亞與赫塞哥雅納 Bosnia and Herzegovina 保加利亞 Bulgaria 克羅埃西亞 Croatia 捷克 Czech Republic 愛沙尼亞 Estonia 法國 France 德國 Germany 匈牙利 Hungary 愛爾蘭 Ireland 義大利 Italy 拉脫維雅 Latvia 盧森堡 Luxembourg 摩納哥 Monaco 荷蘭 Netherlands 波蘭 Poland 摩爾多瓦 Republic of Moldova 俄羅斯 Russian Federation 塞爾維亞 Serbia 斯洛維尼亞 Slovenia 瑞典 Sweden 馬其頓 The former Yugoslav Republic of Macedonia 土庫曼 Turkmenistan 英國 United Kingdom 賽普勒斯 Cyprus 丹麥 Denmark 芬蘭 Finland 喬治亞 Georgia 希臘 Greece 冰島 Iceland 以色列 Israel 哈薩克 Kazakhstan 立陶宛 Lithuania 馬爾他 Malta 蒙特內哥羅 Montenegro 挪威 Norway 葡萄牙 Portugal 羅馬尼亞 Romania 聖馬利諾 San Marino 斯洛伐克 Slovakia 西班牙 Spain 瑞士 Switzerland 土耳其 Turkey 烏克蘭 Ukraine

8 附錄五健康檢查不合格之認定及處理原則檢查項目不合格之認定及處理原則胸部 X 光一活動性肺結核或結核性肋膜炎視為不合格肺結核檢查二非活動性肺結核視為合格, 包括下列診斷情形纖維化 ( 鈣化 ) 肺結核纖維化 ( 鈣化 ) 病灶及肋膜增厚三經診斷為疑似肺結核或無法確認診斷者, 請攜帶體檢報告胸部 X 光片至指定機構再檢查 ; 所在縣市無指定機構者, 得至鄰近醫院之胸腔科門診再檢查四不合格者得留臺治療後重新體檢, 但時間依其停留簽證或入出境許可證之效期為限腸內寄生蟲一經顯微鏡檢查結果為腸道蠕蟲蟲卵或其他原蟲類如痢疾阿米巴原蟲糞便檢查 (Entamoeba histolytica) 鞭毛原蟲類, 纖毛原蟲類及孢子蟲類者為不合格二經顯微鏡檢查結果為人芽囊原蟲及阿米巴原蟲類, 如哈氏阿米巴 (Entamoeba hartmanni) 大腸阿米巴(Entamoeba coli) 微小阿米巴(Endolimax nana) 嗜碘阿米巴 (Iodamoeba butschlii) 雙核阿米巴(Dientamoeba fragilis) 唇形鞭毛蟲 (Chilomastix mesnili) 等, 可不予治療, 視為合格三不合格者得接受治療, 檢具複檢陰性證明者, 視為合格四妊娠孕婦如為寄生蟲檢查陽性者, 視為合格 ; 請於分娩後, 進行治療梅毒血清一具下列任一條件, 視為不合格檢查 ( 一 ) 未曾接受梅毒治療或病史不清楚者, 其血清非特異性梅毒螺旋體試驗及特異性梅毒螺旋體試驗陽性 ( 二 ) 曾經接受梅毒治療者, 其血清非特異性梅毒螺旋體試驗效價 4 倍上升二血清非特異性梅毒螺旋體試驗及特異性梅毒螺旋體試驗 ( 一 ) 非特異性試驗快速血漿反應素試驗 (RPR) 或性病研究實驗室試驗 (VDRL) ( 二 ) 特異性試驗梅毒螺旋體血液凝集試驗 (TPHA) 梅毒螺旋體粒子凝集試驗 (TPPA) 梅毒抗體間接螢光染色法 (FTA-abs) 梅毒螺旋體乳膠凝集試驗 (TPLA) 梅毒螺旋體酵素免疫分析法(EIA) 或梅毒螺旋體化學冷光免疫分析法 (CIA) 三梅毒血清檢查如使用中央衛生主管機關所增列之檢驗方法, 得於其他下增列四不合格者得接受治療, 檢具治療證明者, 視為合格麻疹及德國麻疹或德國麻疹抗體檢查報告為陰性或未確定者, 且未檢具麻疹及德國麻疹預防接種麻疹抗體檢證明者, 視為不合格但經醫師評估有麻疹及德國麻疹疫苗接種禁忌者, 視為合格查漢生病檢查一經診斷為須進一步檢查者, 請至指定機構進一步檢查 ; 所在縣市無指定機構者, 得至鄰近醫院之皮膚科門診二不合格者得留臺治療後重新體檢, 但時間依其停留簽證或入出境許可證之效期為限註胸部 X 光肺結核檢查或漢生病檢查之再檢查指定機構名單請洽衛生福利部疾病管制署 (http// 國際旅遊與健康 / 外國人健檢 / 健檢指定醫院 / 胸部 X 光檢查確認機構名單或漢生病個案確診及治療指定機構

9 Appendix 5 Principles in determining the health examination failed and further procedures Test Chest X-ray for Tuberculosis Stool Examination for Parasites Serological Test for Syphilis Measles and Rubella Antibody test Examination for Hansen s Disease Principles in determining the health examination failed and further procedures 1. Active pulmonary tuberculosis or tuberculous pleurisy is failed. 2. Non-active pulmonary tuberculosis including calcified pulmonary tuberculosis, calcified foci and enlargement of pleura, is considered passed. 3. Those who are determined to be TB suspect or whose results are diagnosed pending diagnosis by the designated hospital in Taiwan must take the report and X-ray films to the referred institution for re-examination; those living in cities/counties without a referred institution, please visit the department of chest medicine at a nearby hospital. 4. People with failed results are allowed to stay for re-examination after receiving treatment, but the duration of stay depends on his/her vistor visa or entry/exit permit. 1. By microscope examination, cases are determined failed if intestinal helminthes eggs or other protozoa such as Entamoeba histolytica, flagellates, ciliates and sporozoans are detected. 2. Blastocystis hominis and Amoeba protozoa such as Entamoeba hartmanni, Entaboeba coli, Endolimax nana, Iodamoeba butschlii, Dientamoeba fragilis, Chilomastix mesnili found through microscope examination are considered passed and no treatment is required. 3. People with failed results can accept treatment, and people with negative re-examination results are considered passed. 4. Pregnant women who have positive result for parasites examination are considered passed and please have medical treatment after the child s birth. 1. Meeting one of the following criterion are considered failed (1) Without past history of syphilis therapy or with unknown history, the non-treponemal test and the treponemal test are positive. (2) With past history of syphilis therapy, the non-treponemal test titers are 4-fold rising. 2. Serological non-treponemal tests and treponemal tests (1) Non-treponemal testsrpr or VDRL. (2) Treponemal teststpha, TPPA, TPLA, EIA, CIA, and FTA-abs. 3. Those who had failed serological test for syphilis but have accepted treatment are considered passed It is considered failed if measles or rubella antibody is negative (or equivocal) and no measles and rubella vaccination certificate issued. Those who have contraindications, not suitable for vaccinations, are considered passed. 1. Those who are determined to need further examinations by the designated hospital in Taiwan must go to the referred institution for further examinations; those living in cities/counties without a referred institution can visit the department of dermatology at a nearby hospital. 2. People with failed result are allowed to stay for re-examination after receiving treatment, but the duration of stay depends on his/her vistor visa or entry/exit permit.

醫院標誌

醫院標誌醫院標誌 Hospital s Logo 健康檢查證明應檢查項目表 ( 乙表 ) ( 醫院名稱地址電話傳真機 ) ITEMS REQUIRED FOR HEALTH CERTIFICATE (Form B) (Hospital s Name, Address, Tel, FAX) 基本資料 ( BASIC DATA) 檢查日期 / / (