[ S.L.36.29 FORMS FOR IMMUNISATION SUBSIDIARY LEGISLATION 36.29 FORMS FOR IMMUNISATION REGULATIONS 25th May, 1992 LEGAL NOTICE 28 of 1982. 1. The title of these Regulations is Forms for Immunisation Regulations. Title. 2.
(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. Forms. Cap. 36.
(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. 1 2 [ S.L.36.29 FORMS FOR IMMUNISATION SCHEDULE (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’ TILQIM TYPE OF VACCINE DATA DO|A DATE DOSE ISEM IT-TABIB L-ewwel do\a First dose NAME OF MEDICAL PRACTITIONER .................... ................. ................. ........................... .................... ................. ................. ........................... 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 FORMS FOR IMMUNISATION [ S.L.36.29 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. 3 4 [ S.L.36.29 FORMS FOR IMMUNISATION 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)
(1)Ni\\el l-Isem Insert Name FORMS FOR IMMUNISATION [ S.L.36.29 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 1istess `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. 5