Vorlage Englisch

Annex 6 WHA58.3

MODEL INTERNATIONAL CERTIFICATE OF VACCINATION OR PROPHYLAXIS

This is to certify that [name] ..................................., date of birth ..................., sex ..............................., 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 Date Signature and Manufacturer and Certificate Official stamp of prophylaxis professional status of batch No. of vaccine or valid from ....... administering centre supervising clinician prophylaxis until ............

1.

2.

This certificate is valid only if the vaccine or prophylaxis used has been approved by the World Health Organization.

This certificate must be signed in the hand of the clinician, who shall be a medical practitioner or other authorized health worker, supervising the administration of the vaccine or prophylaxis. The certificate must also bear the official stamp of the administering centre; however, this shall not be an accepted substitute for the signature.

Any amendment of this certificate, or erasure, or failure to complete any part of it, may render it invalid.

The validity of this certificate shall extend until the date indicated for the particular vaccination or prophylaxis. The certificate shall be fully completed in English or in French. The certificate may also be completed in another language on the same document, in addition to either English or French.