世界衛生組織規定之國際預防接種證明書格式
International Certificate of
Vaccination or Prophylaxis
International Health Regulations (2005)
Certificat international de
vaccination ou de prophylaxie
Règlement sanitaire international (2005)
Issued to / Délivré à
Passport number or travel document number
Numéro du passeport ou du document de voyage
中華民國衛生福利部疾病管制署
Centers for Disease Control,
Ministry of Health and Welfare,
Republic of China (Taiwan)
國際預防接種/預防措施證明書
INTERNATIONAL CERTIFICATE
OF VACCINATION OR PROPHYLAXIS
No
持用人
Issued to
INTERNATIONAL CERTIFICATE OF VACCINATION
OR PROPHYLAXIS
This is to certify that [name]
date of birth
nationality
national identification document, if applicable.
whose signature follows
has on the date indicated been vaccinated or received prophylaxis
against: (name of disease or condition)
in accordance with the International Health Regulations.
Vaccine or prophylaxis
Vaccin ou agent
prophylactique
我國現用國際預防接種證明書
Requirements for validity of certificate en page 2.
兹维明 (姓名)
This is to certify that (name)
date of birth
Date
Date
Signature and profesional
status of supervising
clinician
Signature et titre du
dinicien responsable
國際預防接種/
INTERNATIONAL CERTIFICATE OF
Date Signature and professional status of
supervising dinician or vaccinator
以上面的所由疾病管制署及授權的醫院核發
This certificate has been issued by the Centers for Disease
CERTIFICAT INTERNATIONAL DE VACCINATION
OU DE PROPHYLAXIE
Nous certifions que [nom).
et de nationalité
document d'identification national, le cas échéant
dont la signature suit
a été vacciné(e) ou a reçu des agents prophylactiques à la date
indiquée contre: (nom de la maladie ou de l'affection)
conformément au Règlement sanitaire international.
Certificate valid
from
Manufacturer and
batch no, of vaccine or
prophylaxis
Fabricant da vaccin ou
de l'agent prophylactique
et numéro du ko
de sexe
Certificat valable i
partir du
jusqu'au
*Voir les conditions de validité à la page 3
受種人簽名:
whose signature follows
預防措施證明書
VACCINATION OR PROPHYLAXIS
根據‹際衛生條)屬經受國際預防接種/預防措施
has on the date indicated been vaccinated or received
prophylaxis against:
Manufacturer and batch No.
of vaccine or prophylax
(name of disease or condition)
in accordance with the International Health Regulations.
administering center