【遺體捐贈意向書】Body Donation Registration Form

如本人離世時情況許可，本人願意捐出遺體作解剖教學或培訓之用，並囑咐將遺體贈予香港中文大學醫學院。
I wish if circumstances at the time of my death permit, to bequeath my body for anatomical
examination in relation to teaching and training, and direct that it be offered to the Faculty of Medicine, The Chinese University of Hong Kong.

稱謂 Title

稱謂 Title 先生 Mr 女士 Ms Other Other
捐贈者中文姓名 Full Chinese Name of Donor
(If no Chinese name, please put the full English name instead)
捐贈者英文姓名 (先填上姓氐，然後名字)
Full English Name of Donor (Surname first and then First Name)
請用正楷填寫 In Block Letter 捐贈者英文姓名 (先填上姓氐，然後名字)
Full English Name of Donor (Surname first and then First Name)
請用正楷填寫 In Block Letter 姓氏名字
香港身份證號碼 (只需填寫英文字母及頭3位數字)
HK Identity Card No. (Please fill Prefix and the First 3 Digits)
最多可接受 5 字母個字元 目前已輸入： 0 字母.
住址 Home Address
最多可接受 100 字元個字元 目前已輸入： 0 字元.
出生年份 Year of Birth
必須4 位數. 目前已輸入： 0 位數.
捐贈者聯絡電話 Contact Tel No.
其他聯絡電話 Other Contact Tel No.
捐贈者電郵地址 Email Address
第一見證人一中文姓名
Chinese Name of First Relative
(If no Chinese name, please put the full English name instead)
第一見證人一英文姓名
English Name of First Relative
第一見證人與捐贈者的關係
Relationship to Donor of First Relative
第一見證人一聯絡電話
Contact Tel No. (Relative)
第一見證人一電郵
Email of First Relative
第二見證人一中文姓名
Chinese Name of Second Relative
(If no Chinese name, please put the full English name instead)
第二見證人一英文姓名
English Name of Second Relative
第二見證人與捐贈者的關係
Relationship to Donor of Second Relative
第二見證人一聯絡電話
Contact Tel No. (Relative)
第二見證人一電郵
Email of Second Relative
請於以下空格上按意願加上 ✔ 號（可選多於一項）
Please put a tick '✔' in appropriate box. (may choose more than one option)

請於以下空格上按意願加上 ✔ 號（可選多於一項）
Please put a tick '✔' in appropriate box. (may choose more than one option) 本人已於「中央器官捐贈登記名冊」登記為器官捐贈者，願意捐贈器官，後捐贈遺體。I am an organ donor and I wish to donate my organs for transplantation first. 本人願意捐贈身體作解剖教學之用 (遺體約兩年後火化)。 I agree to donate my body for anatomical examination and for teaching (which takes approx. 2 years). 本人願意捐贈身體作手術練習及醫學培訓之用 (遺體約一年後火化）。 I agree that my body can be used for medical and surgical training (which takes approx. 1 year). 本人願意捐贈身體作標本教學之用 (遺體剩餘約一半至三分一，在兩年至三年後火化)。I agree that my body can be used for making teaching specimens (which takes approx. 2-3 years and only 30-50% of the bodies will be cremated). 本人為獨居或基層人士，若死後合適捐軀，願委託中大協助接送遺體及安排棺木，火化等事宜，以完成成爲無言老師的意願。I am a singleton elderly or grassroots citizen. I authorize the Chinese University of Hong Kong to assist in the transportation and cremation of my body. 本人願意把骨灰撒於“華永會將軍澳紀念花園”內的「無言老師」專區。I wish that my ash is scattered in the The Garden of Remembrance of The Board of Management of The Chinese Permanent Cemeteries.
注意事項 Notes

(1) 如你未能提供上表資料，我們可能無法為你完成登記。
(2) 中文大學醫學院會在你成功登記成為遺體捐贈登記者後，郵寄遺體捐贈卡予登記者。
(3) 如你曾辦理相關登記，但想更改任何資料，請於辦公時間以電話、郵寄或以電郵方式作出通知；如欲取消登記，亦請以電話或以電郵方式通知大學，職員會與閣下聯絡簡單核對資料後，取消你之前所作的登記。

歡迎於辦公時間內 (星期一至五上午9:00至下午5:00，星期六、日及公眾假期除外) 致電3943 6050查詢或傳真至3942 0956
「無言老師」電子郵件 s-teacher@cuhk.edu.hk
「無言老師」網站http://www.sbs.cuhk.edu.hk/bd

(1) If the data provided is incomplete or inaccurate, the registration will be deemed invalid.
(2) A Body Donation Card and a Certificate of Appreciation will be issued to donor when the registration is succeed.
(3) Please contact us within the office hour if you want to withdraw your resignation or update any related information.

Office Hour (Monday - Friday 09:00 - 17:00, excluding Saturdays, Sundays and public holidays)
Tel: 3943 6050 Fax: 39420956
"Silent Teacher" Email Address: s-teacher@cuhk.edu.hk
"Silent Teacher" Webpage: http://www.sbs.cuhk.edu.hk/bd
收集個人資料用途聲明
Statement of Purposes for Collection of Personal Data

本人已閱讀及同意一旦遞交香港中文大學醫學院「遺體捐贈計劃」意向書，本人願意接受下列條款：
I have read and agreed to the following terms and conditions upon submitting my registration for the "Body Donation Programme" at the Faculty of Medicine of The Chinese University of Hong Kong:

(1) 你作出的遺體捐贈登記是出於自願。所收集於香港中文大學醫學院遺體捐贈計劃登記名冊的資料，會被視作個人資料並絕對保密。
(2) 資料主要由解剖實驗室內部使用，亦可能於有所需要時向政府部門，醫療及教育單位或有關人士披露。
(3) 根據香港法例《個人資料(私隱)條例》第 18 條及 22 條以及附表 1 第 6 原則所述，你有權查閱及修正你所提供的個人資料。
(4) 若你有任何有關所提供個人資料(包括查閱，修正及取消資料)的查詢，歡迎與我們聯絡。地址: 新界沙田香港中文大學，李卓敏基本醫學大樓解剖實驗室。
(5) 此意向書代表閣下離世時願意捐贈遺體的意願。對於是否接收遺體，香港中文大學醫學院保留最終決定權。
(6) 未經他人同意而盜用其個人資料在中大遺體捐贈名冊上登記不但屬違法行為，更會影響真正有意願捐贈遺體的市民｡若懷疑有此情況，警方會嚴肅跟進｡

(1) Registration with the Body Donation Programme is voluntary. All personal data contained in this form will be treated in strict confidence.
(2) The collected personal information will be used for access by authorized personnel for handling and processing body donation matters. In additional, information may be disclosed to the government, healthcare system, educational units and relevant parties if necessary.
(3) In accordance with the Personal Data (Privacy) Ordinance Cap. 486 (“Ordinance”) of the Hong Kong Special Administrative Region of the People’s Republic of China, you reserve the right to access, correct and retain the personal information provided.
(4) If you would like to request details of personal information which we hold about you under the Ordinance, please feel free to contact us.
Address: Dissecting Laboratory, Choh-Ming Li Basic Medical Sciences Building, The Chinese University of Hong Kong, Shatin, New Territories.
(5) This registration form represents your wish to bequeath your body for anatomical examination at the time of death permit. The Faculty of Medicine, CUHK reserves the right of final decision on body reception.
Remarks
請輸入圖片所呈現的字元。

【遺體捐贈意向書】Body Donation Registration Form

【遺體捐贈意向書】Body Donation Registration Form

注意事項 Notes

收集個人資料用途聲明 Statement of Purposes for Collection of Personal Data

收集個人資料用途聲明
Statement of Purposes for Collection of Personal Data