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和信治癌中心醫院 2026 年度利益關係揭露問卷 KFSYSCC 2026 Conflict of Interest Disclosure Survey

本問卷分為 5 個部分，預計約 10 分鐘完成。您可以隨時返回上一步修改答案。 This survey has 5 sections and takes about 10 minutes. You can go back to edit any answer at any time.

我們對同仁的倫理期待 Our ethical standard

和信治癌中心醫院的病人，是在生命中最脆弱的時刻來到本院。他們把治療的判斷、用藥的選擇，甚至生死的決定，託付給我們。這份信任，是本院存在的根本。

本院對全體同仁有一個明確的倫理標準：在任何臨床、研究、行政決策上，您所做的判斷必須完全以病人的最佳利益為依歸，不受任何外部財務、個人或商業關係的影響。

Patients come to KFSYSCC at the most vulnerable moments of their lives. They place their treatment, their medication, and sometimes their life-and-death decisions in our hands. That trust is the foundation of why this hospital exists.

KFSYSCC holds all staff to a clear ethical standard: every clinical, research, and administrative judgment must be guided solely by the best interest of the patient, free from outside financial, personal, or commercial influence.

預計時間Time needed 約 10 分鐘About 10 minutes

截止日期Deadline —

資料處理Handled by 由人力資源部收集HR (Human Resources)

本問卷包含以下 5 個部分： This survey covers 5 sections:

身份與決策角色確認Identity and decision-making role
院外職務（系統會帶入您 2024 年的回報）Outside positions (your 2024 entries are pre-filled)
與廠商及產業的互動Interactions with vendors and industry
財務利益、家屬關係、院外臨床工作Financial interests, family relationships, outside clinical work
確認與送出Review and submit

這不是調查，也不是稽核。 本問卷由人力資源部收集，並依個資法規定保密處理，僅供利益衝突委員會審閱。當您不確定某項活動是否需要揭露時，請填寫——由委員會判斷比由您自己判斷更安全。

This is not an investigation or audit. The survey is collected by HR, kept confidential under personal data protection rules, and reviewed only by the COI Committee. When in doubt, please disclose — it is safer to let the committee decide.

身份確認 Identity confirmation

姓名Name 員工編號Employee ID 部門Department 職稱Title 聯絡 EmailContact email

決策角色確認 Decision-making role

為什麼問這題？Why we ask this

依據本院「員工與廠商之行為規範」第 2.8 條，凡對本院儀器、藥品及衛材的使用具有決定權者，或參與採購及議價之人員，不能與廠商有任何利益關係（例如擔任股東、有給職顧問或董事）。為了讓委員會在審閱您的回答時能套用正確的標準，請先告訴我們您是否屬於此類角色。

Under §2.8 of KFSYSCC's Employee and Vendor Conduct Policy, any staff member with decision-making authority over equipment, drugs, or medical supplies — or who participates in procurement or price negotiation — is prohibited from holding any interest relationship with a vendor (such as shares, paid consulting, or a board seat). So that the committee can apply the right standard when reviewing your answers, please tell us first whether you hold any such role.

您目前是否擔任下列任一角色？（可複選） Do you currently hold any of the following roles? (Check all that apply)

藥事委員會（藥委會）委員Member of the Pharmacy and Therapeutics (P&T) Committee 科部主任、副主任或單位主管Department chair, deputy chair, or unit head 參與儀器、藥品或耗材之選用、採購、議價、合約審查或處方集（formulary）納入決策（任一項即可勾選）Involved in selecting, purchasing, negotiating, approving, or making formulary decisions about equipment, drugs, or medical supplies — including procurement, vendor selection, contract review, or drug inclusion decisions (check this if any one of these applies) 其他對廠商產品使用具有決定權之角色（請於下方說明）Other role with decision-making authority over the use of vendor products (please describe below) 以上皆無None of the above

其他角色說明（如有勾選「其他」） Description of other role (if you checked "Other" above)

A. 院外職務 A. Outside Positions

以下是您於 2024 年申報的院外職務。請確認哪些仍持續、哪些已結束。如有新增職務，請點選下方「新增職務」按鈕一併填寫。

Below are the outside positions you reported in 2024. Please confirm which are still active and which have ended. If you have taken on any new positions since 2024, use the "Add another position" button below.

什麼算是「院外職務」？What counts as an "outside position"?

任何在本院以外的組織所擔任的正式或非正式職務，包括但不限於：董事、理事、監事、顧問、委員、講座教授、學會會長或幹部、財團法人董事或執行長、公司負責人或合夥人、編輯委員、評審委員等。無論有給職或無給職，無論全職或兼任，皆需揭露。

Any formal or informal role you hold in an organization outside KFSYSCC, including but not limited to: director, supervisor, board member, advisor, committee member, chair professor, society president or officer, foundation director or CEO, company principal or partner, editorial board member, or review committee member. Disclosure is required whether the role is paid or unpaid, full-time or part-time.

B. 與廠商及產業的互動 B. Industry Interactions

以下問題涉及您與廠商、藥廠或醫療器材公司之間的互動，包括受邀演講、參加贊助會議、擔任顧問、產業贊助研究等。這些活動在學術醫學界相當常見。 我們詢問的目的，是為了讓醫院在面對期刊揭露、研究倫理審查或外部查核時，能夠代您完整說明。

回顧期間：B1 為過去 24 個月，B2 為過去 12 個月。

The following questions cover your interactions with vendors, pharmaceutical companies, and medical device manufacturers — invited talks, sponsored conferences, advisory roles, and industry-funded research. These activities are common in academic medicine. We ask so that the hospital can provide complete information on your behalf when journals, research ethics committees, or external auditors require disclosure.

Lookback period: the past 24 months for B1, the past 12 months for B2.

B1. 與廠商的互動（過去 24 個月） B1. Interactions with vendors (past 24 months)

過去 24 個月內，您是否曾與任何廠商有下列任何形式的互動？（可複選） In the past 24 months, have you had any of the following types of interactions with a vendor? (Check all that apply)

參加廠商（全部或部分）贊助的會議、研討會、進修課程或考察活動Attended a conference, symposium, training course, or site visit that was paid for in whole or in part by a vendor 受廠商邀請擔任講者、授課者，或在廠商主辦或贊助的活動中發表內容Was invited by a vendor to speak, teach, or present at a vendor-organized or vendor-sponsored event 擔任廠商之顧問、諮詢委員、科學顧問會（SAB）成員，或提供有償諮詢服務Served as an advisor, consultant, scientific advisory board (SAB) member, or provided paid consulting services to a vendor 擔任產業贊助研究計畫之主持人（PI）、共同主持人（Co-I）或試驗主持人Served as principal investigator (PI), co-investigator (Co-I), or site investigator on a research project funded by a vendor or industry sponsor 接受廠商或其代筆／醫學寫作公司協助撰寫或潤飾論文、評論文章、會議摘要或演講內容Received drafting or editing assistance from a vendor or vendor-funded medical writer for manuscripts, review articles, conference abstracts, or presentation content 接受廠商提供之器材、設備或軟體之長期借用或免費使用（用於本人、診間、科部或研究室；非短期試用樣品）Accepted long-term loan or free use of equipment, devices, or software from a vendor (for personal, clinic, department, or laboratory use; not short-term sample/demo) 為廠商之新產品、原型或前期版本提供試用、測試或回饋（含 beta 測試與先導使用）Provided beta-testing, pilot use, or product feedback on a vendor's prerelease product or prototype 以上皆無None of the above

如有勾選上述任何一項，請於下方為每一筆互動建立一列並填寫詳細資料。 If you checked any item above, please create one row below for each interaction and fill in the details.

B2. 廠商代表的非正式接觸（過去 12 個月） B2. Informal contact from vendor representatives (past 12 months)

本院政策與本題目的Hospital policy and why we ask

本院「員工與廠商之行為規範」明定：本院不允許廠商與員工個人之間有任何餽贈行為，包括金錢、禮品（含文具）、餐飲及招待出遊等，此政策為零容忍。

我們完全理解，廠商代表有時會在會議、研討會、學術活動或其他社交場合主動提出邀請或饋贈。本題的目的不是要追究責任，而是讓醫院掌握廠商在實務上接觸同仁的方式與頻率。本題詢問的是「廠商主動提出」的情況，並不預設您是否接受。

KFSYSCC's Employee and Vendor Conduct Policy is explicit: the hospital does not permit any gifts between vendors and individual employees — money, gifts (even stationery), food and drink, or entertainment. This policy is zero tolerance.

We fully understand that vendor representatives sometimes make offers in conferences, symposia, academic events, or social settings. The purpose of this question is not to assign blame; it is to give the hospital a realistic picture of how vendors actually approach our staff. This question asks about what vendors have OFFERED, regardless of whether you accepted.

過去 12 個月內，是否曾有廠商或其代表向您提出下列任何項目？（無論您是否接受，可複選） In the past 12 months, has a vendor or vendor representative offered you any of the following? (Regardless of whether you accepted; check all that apply)

院外的商務餐敘或聚餐邀請An invitation to a business meal or social gathering outside the hospital 在會議或研討會場合的餐飲招待Food or drink provided at a conference or symposium 廠商為您支付出席學術會議的機票、住宿或註冊費A vendor offered to cover travel, lodging, or registration for an academic conference 教育材料、書籍或文獻Educational materials, books, or scientific literature 藥品、試劑或耗材樣品Drug, reagent, or consumable samples 具廠商標誌之促銷物品或文具，名義價值（例如筆、筆記本、馬克杯、便條紙等）Branded promotional items or stationery of nominal value (e.g., pens, notebooks, mugs, sticky notes) 具有較高價值的禮品、禮券、有價票券或現金Gifts of more substantial value, vouchers, valuable tickets, or cash 招待出遊、娛樂活動或其他非學術性活動Entertainment, leisure trips, or other non-academic activities 其他形式的招待或贈予Other forms of hospitality or gifts 以上皆無，過去 12 個月內無廠商主動提出任何此類項目None of the above; no vendor has offered me any such item in the past 12 months

當您收到此類提議時，通常如何處理？ How do you typically handle such offers when you receive them?

一律婉拒，不接受任何此類提議I always decline; I do not accept any such offers 婉拒並向廠商說明本院政策I decline and explain KFSYSCC policy to the vendor 視情況而定，有時會接受（例如僅接受會議場合的茶點，但婉拒禮品）It depends on the situation — I sometimes accept (e.g., I accept refreshments at a conference but decline gifts) 通常會接受I generally accept 不適用，未曾遇過此類情況Not applicable; I have not encountered this 不確定如何回答Unsure how to answer

如有任何特殊情況、不確定的接觸經驗，或希望委員會協助處理的事項，請於此說明（可選填） If there is any specific incident, uncertain interaction, or anything you would like the committee to help you handle, please describe it here (optional)

C. 其他利益關係 C. Other Interests

本節涵蓋財務利益、家屬關係，以及院外的臨床工作。同樣地，這些事項本身並不違規。醫院需要掌握這些資訊，是為了在必要時能夠主動為您把關。

家屬定義：配偶、父母、子女、兄弟姊妹，或任何與您同住之人。

This section covers financial interests, family relationships, and outside clinical work. As with the earlier sections, none of these items are inherently improper. The hospital needs this information so we can proactively look out for you when needed.

Definition of family member: spouse, parents, children, siblings, or anyone living in your household.

C1. 財務利益清單（過去 24 個月） C1. Financial interests checklist (past 24 months)

請勾選下列任何適用於您或您家屬的項目（涵蓋過去 24 個月內任何時點）。如有任何不確定之處，請勾選「不確定」並於下方簡述。

Please check any of the following items that apply to you or to a family member at any point during the past 24 months. If you are unsure about any item, please check "Unsure" and add a brief description below.

我或家屬持有任何本院往來廠商的股票、選擇權或股權（無論該廠商為上市、上櫃或未公開），或持有任何未公開上市之醫療相關公司、生技新創、診所、檢驗所或醫療相關事業的股份或股權（無金額門檻，任何持股皆須勾選）。I or a family member hold any stock, stock options, or equity in a KFSYSCC vendor (whether publicly traded or private), OR any ownership stake in a privately held (non-publicly-traded) healthcare-related company, biotech startup, clinic, laboratory, or healthcare-related business (any amount, no minimum threshold). 我或家屬在任何「非本院廠商」之上市櫃醫療相關公司（包括藥廠、醫療器材、診斷試劑、生技、CRO、臨床檢驗或影像、醫療資訊系統、醫療耗材公司等）有重大持股：過去 24 個月內任一時點市值超過 NT$150,000，或持股超過該公司流通股份的 1%。（本院廠商之持股請勾選上方第一項，無金額門檻；本項僅限與本院無業務往來之醫療相關公司，不包括半導體、銀行、地產等與醫療無關的一般持股。）I or a family member hold a significant amount of stock in a publicly traded healthcare-related company that is not a KFSYSCC vendor (pharmaceutical, medical device, diagnostic, biotech, CRO, clinical lab, imaging, medical IT, or medical supply company): more than NT$150,000 in market value at any point during the past 24 months, OR more than 1% of the company's outstanding shares. (Holdings in KFSYSCC vendors should be reported under item #1 above, with no minimum threshold. This item is limited to healthcare-related companies and does NOT include unrelated holdings such as semiconductors, banks, or real estate.) 我持有或申請中與臨床、藥物、器材或研究相關的任何專利或專利申請（不限是否已商業化）。I hold, or have applied for, any patent or patent application related to clinical practice, drugs, devices, or research (whether or not it has been commercialized). 家屬目前受雇於、擁有、經營，或在本院往來廠商擔任主管職務（任何角色，包括業務、研發、行政、行銷等）。A family member is currently employed by, owns, runs, or holds a management role at a KFSYSCC vendor (any role, including sales, R&D, administration, marketing, etc.). 我或家屬曾收受來自任何醫療相關單位的轉介費、介紹費、回扣，或其他與病人轉介或產品使用有關的款項。I or a family member have received referral fees, finder's fees, kickbacks, or any other payment tied to patient referrals or product use, from any healthcare-related entity. 以上皆不適用None of the above applies to me or my family 不確定（請於下方說明）Unsure (please describe in the box below)

補充說明（若勾選任何項目，包括「不確定」，請於此簡述） Brief description (required if you checked any item, including "Unsure")

C2. 院外臨床工作 C2. Outside clinical work

您目前是否有在本院以外的地方執行臨床業務？這包括兼診、代班、定期門診、長期顧問醫師職務、遠距醫療或線上看診，以及任何受薪或收費的臨床服務。不包括偶發性的義診或公益性活動。

Do you currently perform clinical work outside KFSYSCC? This includes moonlighting, covering shifts at another hospital or clinic, regular outpatient sessions, long-term consulting physician roles, telemedicine or online consultations, and any paid or fee-based clinical service. It does NOT include occasional volunteer clinics or charity work.

否No 是Yes 不確定Unsure

地點（診所或醫院名稱） Location (name of the clinic or hospital) 是否與本院上班時間重疊？ Does this work overlap with your KFSYSCC duty hours?

否No 是Yes

您是否曾在此處與本院之間轉介病人？ Have you referred patients between this outside practice and KFSYSCC?

否No 是Yes 不確定Unsure

C3. 其他事項 C3. Anything else

是否有其他關係、活動或利益，無論是過去或現在，可能讓一位理性的同事認為會影響您在本院的專業判斷？當有疑慮時，歡迎告訴我們，我們可以一起看看是否需要任何協助。

Is there any other relationship, activity, or interest, past or present, that a reasonable colleague might view as potentially influencing your professional judgment at KFSYSCC? When in doubt, feel free to share it with us — we can take a look together.

說明（可選填） Description (optional)

確認與送出 Review and Submit

結尾聲明 Closing attestation

我確認以上資訊就我所知為完整且正確。我了解利益衝突委員會將審閱本問卷內容，並可能為了釐清細節與我聯繫。我也了解本問卷的目的是協助我與醫院妥善管理潛在的利益衝突，而非進行調查或追究責任。我也理解本院對同仁的倫理期待：在所有臨床、研究與行政決策上，必須以病人的最佳利益為唯一依歸。

I confirm that the information provided above is complete and accurate to the best of my knowledge. I understand that the Conflict of Interest Committee will review this survey and may contact me to clarify any details. I also understand that the purpose of this survey is to help me and the hospital properly manage potential conflicts of interest, and not to investigate or assign blame. I further acknowledge the ethical standard that KFSYSCC holds for its staff: that every clinical, research, and administrative decision must be guided solely by the best interest of the patient.

我同意上述聲明I agree to the statement above 簽名（請輸入您的姓名） Signature (please type your full name)

已送出Submission received

感謝您完成 2026 年度利益關係揭露問卷。委員會將審閱您的回答，如有需要將與您聯繫。

Thank you for completing the 2026 COI disclosure survey. The committee will review your responses and contact you if needed.

確認編號：Confirmation: