香港中文大學賽馬會公共衞生及基層醫療學院 - 私營醫療機構收費透明度問卷調查 報名表格 The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong - Enrolment Form for Survey on Price Transparency of Private Healthcare Facilities

*註：此表格是參與問卷調查的報名表格，並不是該問卷。研究小組收到報名表格後將會再與合資格的報名人士聯絡。

香港中文大學賽馬會公共衞生及基層醫療學院醫療體系及政策研究所受消費者委員會委託，進行有關香港私營醫療機構收費透明度的研究。此問卷調查主要探討曾在2016年10月1日或之後於私家醫院或私營日間醫療中心接受常見及非緊急手術／程序的市民或其親屬對私營醫療機構收費透明度的經驗及看法。問卷調查會以電話訪問形式進行，需時大約40分鐘。受訪者在完成問卷調查後可得港幣$100以作答謝。每名受訪者只可參加調查一次。您若有興趣參與問卷調查，請填寫以下報名表格。您所提供的資料僅供研究用途，並且將會在研究報告發表後三年後被銷毀。

如果您或您的親屬符合以下條件：
• 年滿18歲；
• 曾於2016年10月1日或之後於私家醫院或私營日間醫療中心接受常見及非緊急手術／程序 (例如大腸鏡檢查、腕管鬆解術、剖腹分娩和激光矯視手術等；請參見下方報名表格第2題以了解所有合資格手術／程序)；及
• 曾就該手術／程序取得服務費用預算。

歡迎填寫下方報名表格。若您符合條件參與問卷調查，研究小組將會與您聯絡，亦請您屆時預備有關手術／程序的服務費用預算及帳單資料作回答問卷之用。如對是次問卷調查有任何疑問，歡迎致電2252-8459。


*Note: This is the enrolment form of the survey only and is not the questionnaire itself. The research team will contact the qualified participants for further survey arrangement after receiving this form.

The Consumer Council has commissioned the Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, the Chinese University of Hong Kong, to conduct a study on price transparency of private healthcare facilities in Hong Kong. This study is to investigate individuals, who received common and non-emergency operations/procedures in private hospitals or private day procedure centres on or after 1 October 2016, or their next-of-kin, for their experience and views about price transparency of private healthcare facilities. The survey will be in the form of telephone survey and will take around 40 minutes. Reward of HKD$100 will be provided upon completion of the survey. Each participant can only take part in the survey once. If you are interested to participate in the survey, please fill in this enrolment form. Data collected under this survey will only be used for research purposes, and will be destroyed 3 years after publishing of the study report.

If you or your next-of-kin meet(s) the following conditions:
• Age 18 or above;
• Received a common and non-emergency operation/procedure (e.g. Colonoscopy, Carpal tunnel release, Caesarean section and LASIK, etc. (Please refer to Q2 of the enrolment form below for the full list of eligible operations/procedures)) on or after 1 October 2016 in a private hospital or a private day procedure centre; and
• Obtained budget estimate for that operation/procedure

Please fill the below form for enrolment. If you meet the eligibility criteria for being invited to participate in this survey, the research team will contact you for further arrangement and invite you to prepare the information in relation to the budget estimate and bill of the relevant operation/procedure for answering the survey questions. If you have any enquiries concerning the survey, please feel free to dial 2252-8459.




個人資料收集聲明

透過回覆此報名表格，您同意所提供的信息及個人資料將由消費者委員會、香港中文大學賽馬會公共衞生及基層醫療學院醫療體系及政策研究所（香港中文大學）及其授權人士共享及處理以用作以下用途：（ａ）分析數據以進行研究，準備及整合研究結果，及出版研究報告；（ｂ）邀請您參加及為您登記參與調查；（ｃ）核實資料及與您進行調查（包括訪問和問卷調查）；（ｄ）跟進聯絡，及（ｅ）其他相關用途，例如項目管理。

您必須在註明（*）的欄目提供所需的個人資料，否則我們可能不能繼續為您處理登記參與及進行調查。

除非獲得您同意，我們不會向消費者委員會、香港中文大學及其授權人士以外的人士或機構轉交您的個人資料，作直銷或其他與上述目的無關的用途。

您可查閱及修正所提供的個人資料。消費者委員會及／或香港中文大學有權就處理其資料查閱及／或修正要求收取費用。有關要求須以書面提出，並郵寄予消費者委員會策劃及商營手法事務主任（地址：香港北角渣華道１９１號嘉華國際中心２２樓）。

消費者委員會及香港中文大學尊重個人資料私隱並承諾遵守《個人資料（私隱）條例》（第４８６章）的保障資料原則及規定。為履行此承諾，我們會致力確保屬下職員依從保安及保密方面的嚴格規定。有關消費者委員會及香港中文大學的私隱政策，請查閱 https://www.consumer.org.hk/tc/privacy-policy 及https://www.cuhk.edu.hk/policy/pdo/b5/ 。

Personal Information Collection Statement

In responding to this enrolment form, you agree that the information and personal data supplied will be shared and processed by the Consumer Council, the Centre for Health Systems and Policy Research, the Jockey Club School of Public Health and Primary Care, the Chinese University of Hong Kong (CUHK), and their authorised personnel for the purpose(s) of (a) analysing the data collected for the purposes of conduct of study, preparation and consolidation of study findings, and publishing of the study report ; (b) inviting you to participate and enrolling you in the survey; (c) verifying information and conducting the survey (including interviews and questionnaire) with you; (d) follow-up communication, and (e) other related purposes such as project management.

It is obligatory for you to provide the personal data marked with asterisks (*). Failure to provide such information may result in us being unable to continue the process of enrolment and the conduct of the survey.

We will not transfer your personal data to parties other than the Consumer Council, the CUHK and their authorised personnel for direct marketing or other purposes unrelated to the above-stated purposes without your consent.

You may request access to and correction of your personal data supplied. The Consumer Council and/or the CUHK may charge a fee for processing any data access and/or correction requests. Such request should be made in writing and addressed to the Consumer Council’s Planning and Trade Practices Officer. (Address: 22nd Floor, K. Wah Centre, 191 Java Road, North Point, Hong Kong).

The Consumer Council and CUHK respect personal data privacy and are committed to complying with the data protection principles and the requirements of the Personal Data (Privacy) Ordinance (Cap 486). In doing so, we strive to ensure compliance by our staff with strict standards of security and confidentiality. For more information about the Consumer Council’s and CUHK’s privacy policies, please refer to https://www.consumer.org.hk/en/privacy-policy and https://www.cuhk.edu.hk/policy/pdo/en/.