和 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 此篇相同回報者之文章列表

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