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社區視覺篩查服務申請表 Community Vision Screening Service Request Form

如閣下對我們的社區視覺篩查服務感興趣，請填寫本表格。

If you are interested in our community vision screening service, please complete this form.

There are 19 questions in this form.
第一部分 Section One

申請機構資料 Applicant Organization

(This question is mandatory)
1. 機構名稱 Organization Name
(This question is mandatory)
2. 機構地址 Organization Address
(This question is mandatory)

3. 服務對象 Service Target(s)

3-1. 特殊需要 Special Need(s)
身體殘障人士 Physical Disabilities
智障人士 Intellectual Disabilities
(This question is mandatory)
4. 年齡範圍 Age Range(s)
(This question is mandatory)
5. 服務性質 Service Type(s)

 

第二部分 Section Two

有關視覺篩查活動場地 Information on space available for screening service set-up

(This question is mandatory)
1. 預計參加人數 Estimated No. of Participants (最少80人 at least 80 ppl)
(This question is mandatory)
2. 可提供場地類別 Available Facility Type(s)
(This question is mandatory)
2-1. 房間數目 No. of Room(s)
(This question is mandatory)
3. 可供使⽤場地的面積(平⽅尺) Total space area for vision screening activity (sq. ft.)
3-1. 視覺篩查活動場地一般需要最少1,000平方尺面積。如貴 機構沒有足夠空間之場地，參加者願意到鄰近之社區會堂以接受服務嗎? We need at least 1,000 ft2 space for our screening site set-up. If you don’t have enough space, would the participants be able to receive the screening service in near-by Community Center?
(This question is mandatory)

4. 擬舉辦活動的日子 Preferred day(s) of the week to conduct the activity

備註: 視覺篩查活動一般需要一整天時間，通常由上午8/9時至下午5/6時

NOTE: In order to best provide student-learning objectives with service-delivery quality, it is expected that we will host a full-day vision screening from 0800/0900 to 1700/1800.

(This question is mandatory)

5. 我們提供義務視覺篩查服務予社會弱勢階層。在完成視覺篩查後，部分參加者有可能需要接受轉介服務如: 全面眼睛檢查及眼鏡驗配等，貴 機構能否資助其有關的費用。

We provide voluntary vision screening service to underprivileged groups in the community. Does your organization have any funding to support follow up services such as comprehensive eye examination and spectacle prescription to those who failed the screening service?

備註: 為使學生能充份了解他們的服務對象，故希望貴 機構能在我們實地視察當天向學生介紹有關 貴機構及服務對象的背景，以及教授面對有特殊需要人士的服務技巧和方法 (如有需要)。 

NOTE: In order to allow our students to better understand and appreciate the needs of your organization and service recipients, please provide a guided tour and introduction of your organization and backgrounds of the service recipients. We shall have students communicate directly with the Contact Person to arrange a student visit at least one month before the vision screening date.

第三部分 Section Three

機構聯絡人資料 Particulars of Representative

(This question is mandatory)
1. 聯絡人 Contact Person
(This question is mandatory)
2. 稱謂 Title
(This question is mandatory)
3. 職位 Position Held
(This question is mandatory)
4. 辦公室電話 Office Tel no.
5. 流動電話 (可選填) Mobile Phone no. (optional)
(This question is mandatory)
6. 電郵地址 Email Address
 
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