FORMS FOR IMMUNISATION REGULATIONS

SUBSIDIARY LEGISLATION 36.29

FORMS FOR IMMUNISATION REGULATIONS

25th May, 1992

LEGAL NOTICE 28 of 1982.

The title of these Regulations is Forms for Immunisation

Regulations.

(Regulation 2)

Form No. 1

~ERTIFIKAT TA’ TILQIM

CERTIFICATE OF VACCINATION

Jiena, hewn ta]t iffirmat, ni``ertifika li .....................................

I, the undersigned, hereby certify that

iben/bint .............................. imwieled/a ............ fi ..................

the son/daughter of

born at

on

u li joqg]od/toqg]od ................................................................

and residing at

[ie/t imlaqqam/a minni kontra d-Difterite, Tetnu u Poljomijelite

kif [ej

has been immunized by me against Diphtheria, Tetanus, and

Poliomyelitis as follows

XORTA TA’

DATA

DO|A

ISEM IT-TABIB

TILQIM

TYPE OF

DATE

DOSE

NAME OF

VACCINE

MEDICAL

PRACTITIONER

L-ewwel do\a

First dose

It-tieni do\a

Second dose

It-tielet do\a

Third dose

Do\i Booster

Booster doses

Firma tat-Tabib

Signature of Medical Practitioner

Isem u Indirizz (ITTRI KAPITALI) ..............................................

Name and Address (IN BLOCK LETTERS)

Data ....................................

Date

Form No. 2

~ERTIFIKAT LI TILQIMA T}ALLIET G}AL DARB’O}RA

CERTIFICATE OF POSTPONEMENT

Jiena, hewn ta]t iffirmat, b’dan ni``ertifika li fil-fehma tieg]i

I, the undersigned, hereby certify that I am of the opinion that

iben/bint ...................... imwieled/a ..................... fi ..................

the son/daughter of

born at

on

u li joqg]od/toqg]od .......................................... mhux fi stat li

and residing at

is not at present

jitlaqqam/titlaqqam kontra d-Difterite, Tetnu u Poljomijelite, u

g]alhekk qed in]alli dan g]al darb’o]ra.

in a fit and proper state to be immunized against Diphtheria,

Tetanus and Poliomyelitis, and I do hereby postpone the

immunization.

It-tarbija g]andha ter[a’ tin[ieb biex titlaqqam fi ..................

Child is to be brought again for immunization on

Firma tat-Tabib

Signature of Medical Practitioner

Isem u Indirizz (ITTRI KAPITALI) ..............................................

Name and Address (IN BLOCK LETTERS)

Data ....................................

Date

NOTA: Meta t-tarbija tkun g]alqet is-sena, dan i`-`ertifikat

g]andu ji[i approvat minn uffi`jal mediku tas-sa]]a.

NOTE: When child is over one year, this certificate must be

approved by a medical officer of health.

Form No. 3

AVVI| LlLL-{ENITURI

NOTICE TO PARENTS

Jiena, hawn ta]t iffirmat, nav\ak li g]andek tlaqqam it-tarbija

(1) ................................

I, the undersigned, hereby give you notice to have the child (1)

.............................. li t-twelid tag]ha issa huwa re[istrat, kontra

d-Difterite, Tetnu u Poljomijelite malli tag]laq it-tliet xhur, skond

id-disposizzjonijiet ta’ l-Ordinanza dwar it-T]aris mill-Mard u

jekk tonqos milli tag]mel hekk tista’ te]el il-penalitajiet stabbiliti

bil-li[i.

whose birth is now registered, immunized against Diphtheria,

Tetanus and Poliomyelitis on reaching the age of three months in

accordance with the provisions of the Prevention of Disease

Ordinance and in default of your doing so you will be liable to the

penalties laid down by the law.

Illum ........................... ta’.......................... 19

.

Dated this ................... of .......................... 19

.

Iffirmat .......................................

Signed

Isem u Indirizz (ITTRI KAPITALI) .......................................

Name and Address (BLOCK LETTERS)

Uffi`jal Anzjan tal-Pulizija inkarigat mid-Distrett ta’ ............

Senior Police Officer in charge of

District.

(1)

Ni\\el l-Isem

(1)

Insert Name

ORDINANZA DWAR IT-T}ARIS MILL-MARD

Tifsir

Il-[enituri, jew kull persuna o]ra li jkollha ta]t il-kura tag]ha

tarbija ta’ i\jed minn tliet xhur, u li mhix imlaqqma kif g]andha

tkun kontra d-Difterite, it-Tetnu u l-Poljomijelite g]andhom jie]du

din it-tarbija f’~entru tat-Tilqim fil-Furjana jew ir-Rabat,

G]awdex, biex ti[i mlaqqma u g]andhom jer[g]u jie]du t-tarbija

g]al aktar do\i skond kif ji[u mitluba mill-uffi`jal inkarigat minn

dan i`-~entru.

Jekk it-tarbija ma tkunx fi stat li tista’ titlaqqam il-[enituri jew

persuna o]ra g]andhom jie]du `ertifikat minghand it-tabib ta`-

`entru tat-tilqim fejn hemm imfisser din i`-`irkostanza, u

g]andhom jer[g]u jie]du t-tarbija fid-data li ti[i ndikata fuq 1-

istess `ertifikat. Meta t-tarbija tkun g]alqet sena dan i`-`ertifikat

g]andu ji[i kkonfermat mill-uffi`jal mediku tas-sa]]a.

II-missier jew l-omm jew kull persuna o]ra b]alma hu msemmi

hawn fuq jistg]u jie]du t-tarbija biex titlaqqam g]and tabib privat.

F’dawn il-ka\i t-tabib privat g]andu jag]ti `ertifikat tat-tilqima/

t]ollija g]al darb’o]ra, skond il-li[i.

PREVENTION OF DISEASE ORDINANCE

Explanatory Statement

Parents or other persons having the custody of a child who is

more than 3 months old and who is not fully protected by

immunisation against Diptheria, Tetanus and Poliomyelitis shall

take such child to an Immunisation Centre in Floriana or Victoria,

Gozo, to be properly immunised and shall take such child again for

further doses as directed by the officer in charge of such centre.

If the child is not in a proper and fit state to be immunised,

parents or other persons should procure from the medical officer in

charge at the centre a certificate to that effect, and shall take the

child again to the centre as directed in the said certificate. When the

child attains the age of one year such certificate is valid only if

approved by a medical officer of health.

It shall be lawful for any parent or other person as aforesaid to

take the child to be immunised by a private practitioner. In such

cases the private practitioner shall forward a certificate of

vaccination/postponement according to law.

(1) The certificate of immunisation required under article

60 of the Prevention of Disease Ordinance shall be drawn up in

accordance with Form No. 1 of the Schedule to these Regulations.

(2) The certificate of postponement of immunisation required

under article 58 of the said Ordinance shall be drawn up in

accordance with Form No. 2 of the Schedule to these Regulations.

(3) The notice required to be given by the Police under article

62 of the said Ordinance shall be drawn up in accordance with

Form No. 3 of the Schedule to these Regulations.