International Certificate of Vaccination or Prophylaxis

1 International Certificate of Vaccination or ProphylaxisInternational Health Regulations (2005)R glement sanitaire International (2005) Certificat International de Vaccination ou de prophylaxieIssued to / D livr Passport number or travel document numberNum ro du passeport ou du document de voyage Requirements for validityThis Certificate is valid only if the vaccine or Prophylaxis used has been approved by the World Health 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 amendment of this Certificate , or erasure, or failure to complete any part of it, may render it validity of this Certificate shall extend until the date indicated for the particular Vaccination or Prophylaxis .

2 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. NotesThe only disease specifically designated in the International Health Regulations (2005) for which proof of Vaccination or Prophylaxis may be required as a condition of entry to a State Party, is yellow fever. When administering this vaccine, the clinician must write Yellow Fever in the space provided on this same Certificate will also be used in the event that these Regulations are amended or a recommendation is made under these Regulations by the World Health Organization to designate another Certificate OF Vaccination OR Prophylaxis CERTIFICAT International DE Vaccination OU DE PROPHYLAXIEC onditions de validit Ce certificat n est valable que si le vaccin ou l agent prophylactique utilis a t approuv par l Organisation mondiale de la Sant.

3 Ce certificat doit tre sign de la main du clinicien m decin ou autre agent de sant agr qui supervise l administration du vaccin ou de l agent prophylactique; il doit aussi porter le cachet officiel du centre habilit qui ne peut, toutefois, tre consid r comme tenant lieu de correction ou rature sur le certificat ou l omission d une quelconque des informations demand es peut entra ner sa nullit .Ce certificat est valable jusqu la date indiqu e pour le vaccin ou l agent prophylactique administr . Il doit tre tabli int gralement en anglais ou en fran ais. Le m me certificat peut aussi tre tabli dans une autre langue, en plus de l anglais ou du fran ais. NotesLa seule maladie sp cifiquement vis e par le R glement sanitaire International (2005) pour laquelle la preuve de la Vaccination ou de la prophylaxie peut tre exig e comme condition d entr e dans un Etat Partie, est la fi vre jaune.

4 Lorsqu il administre ce vaccin, le clinicien doit crire Fi vre jaune dans l espace pr vu sur ce certificat. Ce m me certificat sera galement employ au cas o le R glement serait modifi ou au cas o une recommandation serait faite en vertu de ce R glement par l Organisation mondiale de la Sant pour indiquer une autre maladie. 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 Certificate * OF Vaccination OR PROPHYLAXISV accine or prophylaxisVaccin ou agent prophylactiqueDateDateSignature and professional status of supervising clinicianSignature et titre du clinicien responsableManufacturer and batch no.

5 Of vaccine or prophylaxisFabricant du vaccin ou de l agent prophylactique et num ro du lotCertificate valid from: until: Certificat valable partir du : jusqu au : Official stamp of the administering centreCachet officiel du centre habilit * Requirements for validity of Certificate on page 2. CERTIFICAT* International DE Vaccination OU DE PROPHYLAXIENous certifions que [nom] ..n (e) le .. de sexe ..et de nationalit ..document d identification national, le cas ch ant ..dont la signature suit ..a t vaccin (e) ou a re u des agents prophylactiques la date indiqu e contre: (nom de la maladie ou de l affection) ..conform ment au R glement sanitaire or prophylaxisVaccin ou agent prophylactiqueDateDateSignature and professional status of supervising clinicianSignature et titre du clinicien responsableManufacturer and batch no.

6 Of vaccine or prophylaxisFabricant du vaccin ou de l agent prophylactique et num ro du lotCertificate valid from: until: Certificat valable partir du : jusqu au : Official stamp of the administering centreCachet officiel du centre habilit * Voir les conditions de validit la page 3. 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 Certificate * OF Vaccination OR PROPHYLAXISV accine or prophylaxisVaccin ou agent prophylactiqueDateDateSignature and professional status of supervising clinicianSignature et titre du clinicien responsableManufacturer and batch no.

7 Of vaccine or prophylaxisFabricant du vaccin ou de l agent prophylactique et num ro du lotCertificate valid from: until: Certificat valable partir du : jusqu au : Official stamp of the administering centreCachet officiel du centre habilit * Requirements for validity of Certificate on page 2. CERTIFICAT* International DE Vaccination OU DE PROPHYLAXIENous certifions que [nom] ..n (e) le .. de sexe ..et de nationalit ..document d identification national, le cas ch ant ..dont la signature suit ..a t vaccin (e) ou a re u des agents prophylactiques la date indiqu e contre: (nom de la maladie ou de l affection) ..conform ment au R glement sanitaire or prophylaxisVaccin ou agent prophylactiqueDateDateSignature and professional status of supervising clinicianSignature et titre du clinicien responsableManufacturer and batch no.

8 Of vaccine or prophylaxisFabricant du vaccin ou de l agent prophylactique et num ro du lotCertificate valid from: until: Certificat valable partir du : jusqu au : Official stamp of the administering centreCachet officiel du centre habilit * Voir les conditions de validit la page 3. Disease targetedMaladie vis eDateDateManufacturer, brand name and batch no. of vaccineFabricant du vaccin, marque, et num ro du lotNext booster (date):Prochain rappel (date): Official stamp and signatureCachet officiel et signatureOTHER vaccinations / AUTRES vaccinations Disease targetedMaladie vis eDateDateManufacturer, brand name and batch no. of vaccineFabricant du vaccin, marque, et num ro du lotNext booster (date):Prochain rappel (date): Official stamp and signatureCachet officiel et signature10 Disease targetedMaladie vis eDateDateManufacturer, brand name and batch no.

9 Of vaccineFabricant du vaccin, marque, et num ro du lotNext booster (date):Prochain rappel (date): Official stamp and signatureCachet officiel et signatureOTHER vaccinations / AUTRES VACCINATIONS11 Disease targetedMaladie vis eDateDateManufacturer, brand name and batch no. of vaccineFabricant du vaccin, marque, et num ro du lotNext booster (date):Prochain rappel (date): Official stamp and signatureCachet officiel et signature1 INFORMATION FOR TRAVELLERS1. During holiday or business travel, it is very common for travellers to encounter diseases which either do not exist or have become rare in the country in which they live. Prospective travellers should seek advice from their physician or health department on measures to be taken to protect themselves from illness.

10 In addition to Vaccination against yellow fever, which may be required to enter some countries, protective measures may be advisable against malaria, poliomyelitis, infectious hepatitis, diphtheria, tetanus, and typhoid fever. Other potential health hazards, which although uncommon should not be overlooked, include the effects of unusual climatic conditions, mental strain, diseases resulting from inadequate hygiene, contact with insects and animals, and physical Be sure to tell your doctor about any travelling you have done during the previous twelve months when consulting him/her about any illness after you Vaccination requirements See Information for physicians .1 RENSEIGNEMENTS DESTIN S AUX VOYAGEURS1. Il arrive qu au cours de voyages , des personnes se trouvent expos es des maladies qui n existent pas ou sont devenues tr s rares dans leur pays.