交换生入学申请表

30.word.i.Chines,o.English,statin.you.background,mot ivat ion.an.stud.pla.a.NIU..,阈名、瞽院名耦、地址、W＞傅真檄附件三健康检查瞪明检查项目表（乙表）检查日期—/—/—（年）（月）瞽院檄或吉REQUIRED FORHEALTH CERTIFICATETypeB（日）//Hospitals YTEMSL°g°National Name,Hospitafs Name,Address,Tel,FAX（M）（D）（Y）基本资料（）BASIC DATA氏口:寰别口男乂■口女Female身份瞪字虢.言蔓照虢碣.照片ID No.-----------------------------Passport No.-------------------------------------------------出生年月日//阈籍DateofBirth,----------------------------------Nationality,-------------------------------------------------Photo^室检查LABORATORY EXAMINATIONS-A.HIV抗1§检查SerologicalTest forHIV Antibody:□IW性Positive口5衾性Negative□未硅定Indeterminate饰横口其他a ScreeningTest:DEI ADSerodia Others雁吉忍口其他b ConfirmatoryTest:□Western BlotOthersB.胸部X光检查肺系吉核ChestX-Ray forTuberculosis:妊娠孕嫦可免接受「胸部X光检查」口正常Normal口昇常Abnormal※限大片播影Standard FilmOnly月易内寄生蠡含痢疾阿米巴等原蠡粪便检查探用高隹心渡缩法检查C.Stool examinationfor parasitesincludes Entamebahistolyticaetc.centrifugal concentrationmethod:口随性，槿名Positive,Species口卜含性Negative梅毒血清检查口口剔生□[修性D.Serological Test for Syphilis:Positive Negativea.□RPR b.DVDRL C.DTPHA/TPPA d.□其它OtherE.麻疹及德博|麻疹之抗曾鄢易性横瞬辍告或予真防接槿瞪明proofof positivemeasles andrubella antibody titers ormeasles andrubellavaccination certificates:a.抗It检查Antibody test麻疹抗醴measles antibodytiters口隔性Positive口口含性Negative德威麻疹抗醴口口剔生口除性I rubellaantibodytitersPositive Negative于真防接不命登明b.Vaccination Certificates匚麻疹于直防接彳重考登明Vaccination Certificatesof Measles□德阈麻疹予直防接不重瞪明Vaccination Certificatesof Rubella口幺空瞽白幅平估,有接不重禁忌者,暂不遹宜接不重.c.Havin.contraindications.no.suitabl.fo.vaccination口女叫瞽白稀平估，有接槿禁忌者，暂不遹宜接木重c.Having contraindications,not suitablefor vaccinationc.口尔空瞽白币音平估,有接槿禁忌者暂不遹宜接槿Havingcontraindications,not suitablefor vaccination漫生病^Check-up forHansen,s Disease澳生病果口正常口昇常※视常者，须迤一步探检硅言忍Skin Check-up NormalAbnormal※甘abnormal skinlesion isfound,further skinbiopsy orskin smearis required.病理切片口易性多菌、少菌性【】；者合断依摞雨者之一即菊党性【汕a SkinBiopsy:I Positive-MB,PB Diagnosticif eer ofthempositive]□除性Negative.皮盾抹片口隔性口含性b SkinSmear:Finding bacilliin affectedskin smears6NegativeX皮病灶合彳并感:W丧失或神与至月重大Skin lesionscombined withsensory lossor enlargementof peripheralnerves□有Yes□趣No瞬±—、本表供外籍人士等申言青在台湾定居或居留日寺使用This formis forresidence application.

二、完童蕨以下免辨理健康检查，但鼾氤直防接槿瞪明借查（年满裁以上者，至少接槿勤麻疹、德阈麻疹疫62ij11J苗）.chil.unde..year.ol.i.no.necessar.t.hav.laborator.examination.bu.th.certificat.o.vaccinatio.i.necessary.Chil.ag.on.an.abov.shoul.ge.a.leas.on.dos.o.measle.an.rubell.vaccines.

三、妊娠孕嫦及完童蕨以下免接受「胸部光检查」12X Apregnant womanorachild under12years oldis notnecessary tohave chestX-rayexamination.

四、兄童羲以下免接受「抗醴检查」及「梅毒血清椀查」15HIV Achild under15years oldis notnecessary tohave SerologicalTestforHIVor Syphilis.

一、人^免疫缺乏病毒抗^初步淇唁式，速^二次呈II性反鹰者，鹰以西方墨黑占法（WB）作碓毒抗醴检查瞬

二、速^二次（探血畤^需隔三他月）西方墨黑占法结果皆卷未碓定者，视卷合格I_______________

二、速^二次（探血日寺^需^隔三彳固月）西方墨黠法结果皆悬未硅定者，视悬合格胸部光检查-

一、活勤性肺结核（包括结核性肋膜炎）视悬「不合格」X

二、非活勤性肺结核视卷「合格」，包括下列^断情形雉化（金丐化）肺结核雉化（短化）病灶及肋膜增厚

二、非活访性肺解亥视卷「合格」，包括下列粉断情形缴雉化（金丐化）肺幺吉核、球隹化（金丐化）病灶及肋膜增厚

二、非活薪性肺缄亥^^「合格」，包括下列情形名就雉化侈丐化）肺僦亥、•隹化窜化）病灶及肋膜增厚踢内寄生蠡翼便

一、微金竞椀查幺吉果卷道蠕蠹蠡卵或其他原蠹类直如痢疾阿米巴原蠡（）＞鞭检查毛At Entamoebahistolytica原蠡毛原蠹^及抱子蠡^者卷不合格

二、余空^微拿竟检查余吉果卷人芽囊原蠡及阿米巴康蠡颊如哈氏阿米巴（Entamoebahartmanni）＞大月易阿米巴（Entamoeba coli）＞微小阿米巴（Endolimax nana）＞嗜碘阿米巴（lodamoeba butschlii）＞ft核阿米巴（Dientamoeba fragilis）等，可不予治墉「合格」

三、妊娠孕孀如卷寄生蠡检查随性者，视卷合格；^於分娩接，暹行治瘵_______________

四、妊娠孕孀如卷寄生蠡检查随性者，^^合格；^於分娩接，迤行治瘴梅毒血清检查

一、以RPR或VDRL其中一槿加上TPHA（TPPA）之旅瞬，如横瞬余吉果有下列情形任一者，「不合格」:

（一）活性梅毒同日寺符合修件

（一）及

（二）、或彳堇符合修件

（三）者

（二）非活性梅毒僮符合修件

（二）者

二、修件

（一）陶床症状出现硬下疳或全身性梅毒缸疹等陶床症状

（二）未曾接受梅毒治瘵或病史不清楚者,RPR（+）或VDRL（+）,且TPHA（TPPA）=1:320以上（含320）

（三）曾^接受梅毒治瘵者,度数上升四倍VDRU

三、梅毒血清检查随性者，检具治瘴明，视卷合格II_________________

三、梅毒血清检查随性者,检具治瘴陶明,^^合格麻疹、德阈麻疹麻疹、德麻疹抗髅性且未检具麻疹、德麻疹防接槿明者卷不合格但^瞽肺押估有麻疹、德阈麻疹疫HI IIli JRII苗接槿禁忌者，视卷合格Appendix:Principles indetermining thehealth statusfailedPrinciples onthe determinationof faileditemsTestIteml.I.th.preliminar.testin.o.th.serologica.tes.fo.HLantibod.i.positiv.fo.tw.consecutiv.times.confirmatio.testin.b.W.i.required.Serolo

2.Whe.finding.o.tw.consecutiv.W.testin.bloo.specimen.collecte.a.a.interva.o.thre.months.ar.indeterminate.thi.ite.i.considere.qu alified.gical

2.When findingsof twoconsecutive WBtesting bloodspecimens collectedat aninterval ofthree monthsare indeterminate,this itemisTest forconsidered qualified.HIVAntibodyChestX-ray l.Activ.pulmonar.tuberculosi.includin.tuberculou.pleurisy.i.unqualified.

2.Non-activ.pulmonar.tuberculosi.includin.calcifie.pulmonar.tuberculosis.calcifie.foc.an.enlargemen.o.pleura.i.considere.qualif ied.

2.Non-active pulmonarytuberculosis includingcalcified pulmonarytuberculosis,calcified fociand enlargementof pleura,is consideredqualified.Stool l.B.microscop.examination.case.ar.determine.unqualified.intestina.helminthe.egg.o.othe.protozo.suc.a.Entamoeb.histolytica.flExami agellates.ciliate.an.sporozoan.ar.detected.nation

2.Blastocysti.homini.an.Amoeb.protozo.suc.a.Entamoeb.hartmanni.Entaboeb.coli.Endolima.nana.Iodamoeb.butschlii.Dientamfor oeb.fragili.foun.throug.microscop.examinatio.ar.considere.qualifie.an.n.treatmen.i.required.Parasit

3.Pregnan.wome.wh.hav.positiv.resuLfo.parasite.examinatio.ar.considere.qualifie.an.pleas.hav.medica.treatmen.afte.delivery.es

3.Pregnant womenwho have positive resultfor parasitesexamination are considered qualifiedand pleasehave medicaltreatment afterdelivery.SerologicalTest forSyphill.Afte.testin.b.eithe.RP.o.VDR.togethe.wit.TPHATPPA.i.case.mee.on.o.th.followin.situation.ar.considere.failin.th.examin ation.islActive syphilis:must fitthe criterion1+2or onlythe criterion

3.2Inactive syphilis:only fitthe criterion

2.

2.Criterion:lClinical symptomswith genitalulcers chancresor syphilisrash allover thebody.2No pastdiagnosis ofsyphilis,a reactivenontreponemal testi.e.,VDRLor RPR,and TPHATPPA=1:320t including1:3203A pasthistory ofsyphilis therapyand acurrent nontreponemaltest titerdemonstrating fourfoldor greaterincrease fromthe lastnontreponemaltest titer.

3.Thos.tha.hav.positiv.result.fo.serologica.tes.fo.syphili.submittin.medica.treatmen.certificat.ar.considere.qualified.

3.Those thathavepositiveresults forserological testfor syphilissubmitting medicaltreatment certificateareconsideredqualifled.Measl Th.ite.i.considere.unqualifie.i.measle.o.rubell.antibod.i.negativ.an.n.measles.rubell.vaccinatio.certificat.i.provided.Thos.wh.haes,vin.contraindications.no.suitabl.fo.vaccination.ar.considere.qualified.Rubell a01/01/2009修言丁。