Appendix 2 APPLICATION FOR ACCESS TO INFORMATION (Page 1) 㱗㡅䈅㮿㙇䓼㥲㯟

(This form can be completed either in English or Chinese. Please read the notes below before writing.) 㺛㙫㥲㯟㗿㙂㫜㖼㢶㕻㖼䃒䐘ボ䃒䐘㦩䓼㹀䕇㥲㯟㕎㬍㤿㻐䀽マ

Applicant's Particulars 㙇䓼㕁㬯㕁䈅㮿 Mr 㙱㙁 Name Mrs 㖩㕁 㡷㚊 Miss 㕩㡴 Correspondence Address 㺝㲩㚔㝍 Tel No. Fax No. 䉋䇷䇔䒦 䂨㰭䇔䒦

Information Requested 㫬㞱㱗㡅㤿䈅㮿 (For information kept by Authority Head Office (HAHO) To : Access to Information Officer or for information kept by more than one hospital, please address 㫎 : 㖔䂀䈅㮿㗚㙨 the application to the HAHO Access to Information Officer. For information kept by one hospital only, please write to the Hospital Access to Information Officer directly. Addresses are given in the back of the application form.) ______(㱗㡅㙅䠢㳑䌳㸉㝫䜢䙒㠑㹮㦓㚦㤿䈅㮿㢶㙅㠭䂂䠢㳑㗞㕐㦓 㚦㤿䈅㮿ボ䓼㵀㙇䓼㥲㙚㢡䠢䌳㝫䜢䙒㠑㹮㖔䂀䈅㮿㗚㙨マ 㱗㡅㘋㙅㔹䂂䠢㳑㦓㚦㤿䈅㮿ボ䓼㥂㶅㚉䇮䠢㳑㤿㖔䂀䈅㮿 䠢㳑䌳㸉㝫 㗚㙨㙇䓼マ㕐㫸㕁㭗㤿㚔㝍㙿㣛㙇䓼㥲㯟㫇㬍マ )

Details of information requested (Please be as specific as possible: it will help us identify clearly what you are looking for. Use a separate sheet if necessary.) 㢺䏏䈅㮿䇯㵱 (䓼䌞䁴㠮䧽䎓㣢ボ㗞㦏㞈㬨衲䄟㥃䈞㜑䏏㫬㤿㨰㪅䏤䈅㮿マ㚣㛄䏏㫬䓼㘊㬒㯊䐘マ )

Signature ______Date ______䢋䆭 㗀㽨 Notes 㻐䀽 1. A charge reflecting the cost of reproducing the records concerned may be levied. The Hospital Authority will advise you in advance of any such charge. 㘯㝫䄜㨘䅑䠍㙿㪵䙣㢺䏏㤿㚹㘯㚽㡅䁒㙂ボ㠎䉑㙱㜹㥃㜑㢺䏏䢔㗟㤿䁒㙂マ

2. You may be asked to provide additional information to help us meet your request. The Hospital Authority may not be able to process your application if you do not provide sufficient information. 㜑㢶䏏㽊㠜㞡㚛䈅㮿ボ㗞㠾㜥㞈㬨㚑䚶㜑㤿㙇䓼マ㚣㜑㘰㱶㽊㠜㟷㴪䈅㮿ボ㘯㝫㗿㱶㾲㤒㹮㸉㜑㤿㙇䓼マ

3. The information provided will be used for processing your application for access to information. It may be divulged to other departments/agencies for the same purpose. 㜑㢺㽊㠜㤿䈅㮿ボ㵀㙂㣛㹮㸉㛄䣐㜑㙇䓼㱗㡅䈅㮿㤿㠑㢃㕐マ㛄䣐䈅㮿㗿㱶䄜㲺㙚㠯㗢㺫㥾/䗀䋚ボ㜐㚃䑚㙂㺪マ

(chi99-03) (revised on April 02) Appendix 2 (Page 2) Address of Access to Information Officers in the Hospital Authority

(a) For information kept by the Hospital Authority Head Office (HAHO) or for information kept by more than one hospital, please write to the HAHO Access to Information Officer in the following address : 㱗㡅㙅䠢㳑䌳㸉㝫䜢䙒㠑㹮㢶㙅㠭䂂䠢㳑㗞㕐㦓㚦㤿䈅㮿ボ䓼㵀㙇䓼㥲㴺㢡㗞㕎㚔㝍モ

HAHO Access to Information Officer 㔾䚘㠓㪑㛢䀷147B䇔 Enquiry No. 2300 6555 Hospital Authority Building 䠢㳑䌳㸉㝫㕣䑢 㩅䇺䉋䇷 147B Argyle Street 䠢㳑䌳㸉㝫䜢䙒㠑㹮 Fax No. 2890 7726 㖔䂀䈅㮿㗚㙨 䂨㰭䇔䒦 (b) For information kept by one hospital only, please write to the respective Hospital Access to Information Officer in the following addresses : 㱗㡅㘋㙅㔹䂂䠢㳑㦓㚦㤿䈅㮿ボ䓼㵀㙇䓼㥲㴺㢡㛄䣐䠢㳑㤿㖔䂀䈅㮿㗚㙨ボ㚔㝍㚣㕎モ

Hospital Access to Information Officer 㖔䂀䈅㮿㗚㙨 Hospital Address 䠢㳑㚔㝍 Fax No. 䂨㰭䇔䒦 㬗㾋㴂 Cheshire Home, Chung Hom Kok 㹗张㟯䃯㗊䥶袜㳑 128 Chung Hom Kok Road, HK 28138980 㬗㾋㹗张㟯䈞 128 䇔 Duchess of Kent Children's Hospital at Sandy Bay 㕣㕟䛷㯓䐨㖔䛲㖩㕁㠫㿧䠢㳑 12 Sandy Bay Road, Pokfulam, HK 28550684 㬗㾋䝁㞍㣳㕣㕟䛷䈞 12 䇔 䇊䁴㩙䠢㳑 125 Wong Chuk Hang Road, Aberdeen, HK 25542011 㬗㾋㗠䂡㛜㝌䈞 125 䇔 MacLehose Medical Rehabilitation Centre 㻋㸉㯽㼨㵖㳑 7 Sha Wan Drive, Pokfulam, HK 28557350 㬗㾋䝁㞍㣳㞳䨪㮗 7 䇔 Pamela Youde Nethersole Eastern Hospital 㣭㴂㖮䐨㖩㕁㠅㘨㱖䠢㳑 3 Lok Man Road, Chai Wan, HK 25150794 㬗㾋㯜䨪䑥㘵䈞 3 䇔 Queen Mary Hospital 䌔䣫䠢㳑 102 Pokfulam Road, HK 28175496 㬗㾋䝁㞍㣳䈞 102 䇔 㨁㽗㤝䠢㳑 266 Queen's Road East, , HK 25916886 㬗㾋䨪㗠㪒㚍㕣䈞㣭 266 䇔 St. John Hospital 㥽㩘䠢㳑 Hospital Road, Tung Wan, Cheung Chau 29819050 㥽㩘㣭䨪㥽㩘䠢㳑䈏 䔳䍚㴠䠢㳑 282 Queen's Road East, Wan Chai, HK 25916886 㬗㾋䨪㗠㪒㚍㕣䈞㣭 282 䇔 Tung Wah Eastern Hospital 㣭䀜㣭㳑 19 Eastern Hospital Road, So Kon Po, Causeway Bay, HK 21626333 㬗㾋䎻䩅䨪㶍㶼㭣㣭㳑䈞 19 䇔 㣭䀜䠢㳑 12 Po Yan Street, Sheung Wan, HK 25594802 㬗㾋㕐䛷㽝㖆䀷 12 䇔 TWGHs Fung Yiu King Hospital 㣭䀜㕍㳑䂟㻽䄑䠢㳑 9 Sandy Bay Road, Pokfulam, HK 28559565 㬗㾋䝁㞍㣳㕣㕟䛷䈞 9 䇔 䢳㟩䠢㳑 30 Hospital Road, Sai Ying Pun, HK 28580952 㬗㾋㛹䛪䒚䠢㳑䈞 30 䇔 Wong Chuk Hang Hospital 䂡㛜㝌䠢㳑 2 Wong Chuk Hang Path, Wong Chuk Hang, HK 25547318 㬗㾋䂡㛜㝌䂡㛜㝌㮗 2 䇔 Kowloon 㔾䚘㴂 㣢䃲䠢㳑 111 Wing Hong Street, Shamshuipo, KLN 27855755 㔾䚘㷯㗋窞㘷㵖䀷 111 䇔 䨙䊢䠢㳑 8 Haven of Hope Road, Tseung Kwan O, KLN 27038028 㔾䚘㵀㫶䗌䨙䊢䈏 8 䇔 Hong Kong Buddhist Hospital 㬗㾋㜃㶠䠢㳑 10 Heng Lam Street, Lok Fu, KLN 23383445 㔾䚘䑥㼒㞤㣳䀷 10 䇔 㬗㾋㸡㪫䠢㳑 147K Argyle Street, KLN 27143922 㔾䚘㠓㪑㛢䀷 147K HK Red Cross Blood Transfusion Service 㬗㾋㪴㕊㚥䄜䙏㛶㣨㳻㕻㖶 15 King's Park Rise, KLN 27801862 㔾䚘㠕㕡㩇䈞 15 䇔 㔾䚘䠢㳑 147A Argyle Street, KLN 27607608 㔾䚘㠓㪑㛢䀷 147A 䐤䀜䠢㳑 25 Waterloo Road, KLN 35175481 㔾䚘䌰㘨㛢䈞 25 䇔 Our Lady of Maryknoll Hospital 䆱㘴䠢㳑 118 Shatin Pass Road, Wong Tai Sin, KLN 23276852 㔾䚘䂡㕣㗦㞳㙄䰦䈞 118 䇔 Queen Elizabeth Hospital 㙠㜡㞳㜒䠢㳑 30 Gascoigne Road, KLN 27839575 㔾䚘㗱㕡㢈䈞 30 䇔 Rehabaid Centre 㼨㵖㴿㪫㖥䈅䄻㕻㖶 G/F, Core S, The HK Polytechnic University, Hung Hom, KLN 27645038 㔾䚘㪴张㬗㾋㸉㕮㕣䖐 S 㮔㚔㕎 㵀㫶䗌䠢㳑 2 Po Ning Lane, Hang Hau, Tseung Kwan O 21770161 㵀㫶䗌㝌㕟䣸䊟㠈 2 䇔 TWGHs Wong Tai Sin Hospital 㣭䀜㕍㳑䂡㕣㗦䠢㳑 124 Shatin Pass Road, KLN 23286137 㔾䚘㞳㙄䰦䈞 124 䇔 United Christian Hospital 㴥䅼㶠䜲㚋䠢㳑 130 Hip Wo Street, Kwun Tong, KLN 35135789 㔾䚘䨮䃎㠾㡗䀷 130 䇔 䄓㪈㴂 Alice Ho Miu Ling Nethersole Hospital 䂏䣫㗊㜄㝜䥍㠅㘨㱖䠢㳑 11 Chuen On Road, Tai Po, NT 26621690 䄓㪈㕣㭣㙲㚪䈏 11 䇔 㙉㽝㸉䊟袜㕻㖶 17 A Kung Kok Shan Road, Shatin, NT 26374111 䄓㪈㞳㙄㠓㖔㟯㕬䈏 17 䇔 㦇㕬䠢㳑 15 Tsing Chung Koon Road, , NT 24559330 䄓㪈㖰㥾㦇㣸䨮䈏 15 䇔 Cheshire Home, Shatin 㞳㙄䃯㗊䥶袜㳑 30 A Kung Kok Shan Road, Shatin, NT 26351492 䄓㪈㞳㙄㠓㖔㟯㕬䈏 30 䇔 䇅㯾䠢㳑 3-15 Kwai Chung Hospital Road, NT 27457610 䄓㪈䇅㯾䠢㳑䈏 3-15 䇔 㗵㴂䠢㳑 9 Po Kin Road, Fanling, NT 26838383 䄓㪈㱑䚰㦓㳪䈏 9 䇔 㻟䃲䠢㳑 Au Tau, Yuen Long, NT 24439593 䄓㪈㖏㯍䰦䙾 Princess Margaret Hospital 䌔䉽㰈䠢㳑 2-10 Princess Margaret Hospital Road, NT 27863629 䄓㪈䌔䉽㰈䠢㳑䈞 2-10 䇔 23703443

Prince of Wales Hospital 㧤䌍㽜䘱㗔䠢㳑 30-32 Ngan Shing Street, Shatin, NT 26378244 䄓㪈㞳㙄䎺㧒䀷 30-32 䇔 㞳㙄䠢㳑 33 A Kung Kok Street, Ma On Shan, Shatin, NT 26477850 䄓㪈㞳㙄㳛䕍㕬㠓㖔㟯䀷 33 䇔 㕩䨩䠢㳑 16½ Milestone, Castle Peak Road, NT 31270228 䄓㪈㦇㕬㖔䈏 16 㧁㗸 㕣㭣䠢㳑 9 Chuen On Road, Tai Po, NT 26650034 䄓㪈㕣㭣㙲㚪䈏 9 䇔 㖰㥾䠢㳑 Tsing Chung Koon Road, Tuen Mun, NT 24551911 䄓㪈㖰㥾㦇㣸䨮䈏 㖆䛜䠢㳑 7-11 Yan Chai Street, Tsuen Wan, NT 24148562 䄓㪈㲔䨪㖆䛜䀷 7-11 䇔

(revised on Feb 05)