ehr Service Provider (SP) Training Scheme Application Form

Transcription

1 ehr Service Provider (SP) Training Scheme Application Form Application for ehr SP training scheme can be submitted throughout the year. Company Application is suitable for IT Vendor whereas individual Application is for Private Healthcare Provider. The Application Form can be downloaded from the ehro website ( Submission of Application Form: Applicants should submit the completed application form by post, facsimile or electronic mail to ehro. Chief Management Services Officer (ehealth Record) ehealth Record Office, Food and Health Bureau, Room 608, 6/F, Murray Road, Multi-storey Carpark Building, 2 Murray Road, Hong Kong : (852) [email protected] For all application, applicants should also provide a copy of the Business Registration Certificate and/or the Certificate of Incorporation (of the IT vendor for company application, and of the private healthcare provider for individual application). In order to meet the training schedule in early 2014, submission of application on or before 25 vember 2013 is much appreciated.

2 Form A Company Application (For IT Vendor) A. Company Details 1. Company Name 2. Business Registration Number 3. Company Address 4. Company Website 5. Contact Person Name and Position Tel. (Office) 6. Company History Company set up for IT project implementation IT support Healthcare service less than 5 year 5 less than 7 years 7 less than 10 years 10 years or longer 0-1 year 5-7 years Over 7 years 0-1 year 5-7 years Over 7 years Over 4 years 7.. of Staff 0-2 staff 3-5 staff 6-9 staff Over 9 staff 8.. of Staff to support CMS On-ramp 9. Support Hotline Telephone Office Hours 10. Services Offerings 0-2 staff 3-5 staff 6-9 staff Over 9 staff Tel. (Mobile)

3 Installation of CMS On-ramp and ELSA CMS On-ramp customisation Hardware setup and configuration Network setup and configuration Server hosting Data migration Hardware rental/loan Hardware rental/loan On-site maintenance support B. Company Expertise 1. Professional Certification Please specify: 2. Windows XP, Windows Vista, Windows 7, Windows 8 and Basic Mac OS knowledge 3. Apache HTTP Server installation and configuration 4. Application server such as Tomcat, JBoss, Weblogic installation and configuration 5. Database such as MS SQL, MySQL, Postgre SQL installation and configuration 6. System Backup and Restore 7. Security Risk Assessment (SRA) 8. Familiar with LAN environment and basic network knowledge C. For Company involved in CMS On-ramp enhancement only Java programming Google Web Toolkit programming Over 2 years Over 2 years

4 D. Declaration of Information THE UNDERSIGNED (FULL NAME) CERTIFY THAT THE INFORMATION FURNISHED ON THIS APPLICATION FORM IS TRUE AND CORRECT. Name of Authorised Person Date Signature of Authorised Person Company Chop

5 Form B Individual Application (For Private Healthcare Provider) A. Healthcare Provider (HCP) Details 1. HCP Name 2. Business Registration Number 3. HCP Address 4. HCP Website 5. Person Applying for Training Name and Position Tel. (Office) B. Declaration of Information Tel. (Mobile) THE UNDERSIGNED (FULL NAME) CERTIFY THAT THE INFORMATION FURNISHED ON THIS APPLICATION FORM IS TRUE AND CORRECT. Name of Person Applying for Training Date Signature of Authorised Person of Healthcare Provider Company Chop te The purpose of collecting company and personal data by the ehealth Record Office of the Food and Health Bureau of HKSARG is to process the application under the ehr Service Provider Training Scheme and to carry out subsequent follow-up work only.