SN∕T 1306-2017 出入境人员预防接种或预防措施国际证书签发规程(出入境检验检疫).pdf

书 书 书?犛犖犜 ? ?犘 狉 狅 狋 狅 犮 狅 犾 狊狅 犳犻 狊 狊 狌 犻 狀 犵犻 狀 狋 犲 狉 狀 犪 狋 犻 狅 狀 犪 犾犮 犲 狉 狋 犻 犳 犻 犮 犪 狋 犲狅 犳狏 犪 犮 犮 犻 狀 犪 狋 犻 狅 狀狅 狉狆 狉 狅 狆 犺 狔 犾 犪 狓 犻 狊犳 狅 狉犲 狓 犻 狋 犲 狀 狋 狉 狔狆 犲 狉 狊 狅 狀 狀 犲 犾 ? ? ?书 书 书? ?。? ? 。? ?，?： ?： “?”?“?” 、 “?”?“?” ； ?： “?”?； ?，?； ?、?； ? 、? ，? 、 、? 、 。?。?：?、?、?。?：?、?、?、?、?、?。?： 、 。犛犖犜 ?、?、?。?、?。?。 ?狆 狉 狅 狆 犺 狔 犾 犪 狓 犻 狊?，?、?。 ?犮 狅 狀 狋 狉 犪 犻 狀 犱 犻 犮 犪 狋 犻 狅 狀犮 犲 狉 狋 犻 犳 犻 犮 犪 狋 犲?。 ?狋 狉 犪 狀 狊 犮 狉 犻 犫 犲 犱犳 狉 狅犿狏 犪 犮 犮 犻 狀 犪 狋 犻 狅 狀犺 犻 狊 狋 狅 狉 狔?（?）?，?。? ?、?（?“?” ） 。 ?，?，?；?，?，?；?，?，?，?。? ?（?“?” ） ，?、?、?。?犛犖犜 ?。?。 ? ?，?、?。 ?（?）?，?。 ?。“?”?。?，?，?。?。 ?，?，?；?、?、?。 ?。?、?、?；?、?、?，?，?，?。 ?： ?，?，?； ?，?、?（?，?、?） ； ?，?。?，?，?（?） ；?，?。 ?、?，?。 ?。? ?： ?； ?； ?； ?； ?； ?（?） ； ?； ?，?，?； ?； ?； ?； ?（?） ； ?，?（?） ； ?。 ?：犛犖犜 ?； ?； ?； ?； ?； ?（?） ； ?； ?； ?； ?； ?。?，?。犛犖犜 ?犃（?）?犃 ?，? 。?，?，?。? ?，?（?） ，? ?。犪）?犫）?犃 ?犛犖犜 预防接种或预防措施国际证书INTERNATIONAL CERTIFICATE OF VACCINATION OR PROPHYLAXIS 根据国际卫生条例)(2005) In accordance with the Intemational Health Regulations(2005) 中华人民共和国出撞撞撞检疫ENTRY-EXIT INSPECTION AND QUARANTINE OF THE PEOPLES REPUBLIC OF CHINA 犮）?犱）?犃 （?）犛犖犜 编号/No:注意事项l本证书的签发需符合出入境人员预防接种或预防措施国际证书签发规程的要求。2除黄热病疫苗外，本证书还包含其他疫苗接种记录，建议长期保存。3旅行者在接种前应如实填写预防接种申请单，告知医生将前往的国家或地区，说明病史、过敏史、接种史，以及目前用药及娃振情况，以便得到相关的旅行健康建议。接种后，需遵循医嘱:如有不适，请及时寻求医疗救助。4可通过世界卫生组织相关网页(www.who. int/ith/en/)来获取针对各个国家的预防接种推荐信息。NOTES l .The issuing ofthis certificate shaIl meet the requirement ofthe Protocols of issuing intemational certificate of vaccination or prophylaxis for entry-exit personnel 2.Besides yeIlow fever vaccination, other vaccinations administrated缸ealso contained on this booklet. lt is, therefore, s甘Onglyrecommended出atyou keep this booklet for a long time 3. Before vaccination, travelers should fiIl in application fo口nsfaithfuIly, teIling由ec1inician the countries or regions to go, the information about their histories of diseases, aIlergy and vaccination, current medications and pregnancy status. A丘ervaccination, travelers should follow the notice ofpost-vaccination; iffeeling unweIl, please seek medical advice at once 4. The information about global recommendation per country regarding vaccination can be found on the website (www who.int/ith/en/) 犲）?犳）?犃 （?）犛犖犜 根据国际卫生条例，在指明的日期接种了疫苗或接受了预防措施以防止z黄热病疫苗Has on the date indicated been vaccinated or received prophylaxis against (name of disease or condition) Yellow F in accordance with the Internatioal Heal th Regulations 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章of supervising clin ician Official stamp of administering center 疫苗或预防措施生产厂商及批号Manufacturer and batch No of vaccine or prophylaxis 证书有效期从至Certi ficate valid from until 根据国际卫生条例)，在指明的日期接种了疫苗或接受了预防措施以防止z黄热病疫苗Has on the date indicated been vaccinated or received prophylaxis against (name of disease or condition) : Yellow Fever in accordance with the International Heal th Regul ations 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章of supervising c1inician Official stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 证书有效期从至Certificate valid from until 犵）?犺）?犃 （?）犛犖犜 其他预防接种或预防措施证明CERTIFICATE OFfHER VACCINATION OR PROPHYLAXIS 疫苗或预防措施(商品名，若有Vaccineor prophylaxis (Brand name, if applicable ) 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章of supervising c1inician Official stamp o( 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用Duration ofprotection (ifapplicable) 唾疫苗或预防措施(商品名，若有Vaccineor prophylaxis (Brand nam e, if applicable) 日期Date监督执行医师签名和专业情况S ignature and professional status 施种机构的印章of supervising c1inician Official stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(着适用)Duration of protection (if applicable) E 犻）?犼）? ?犃 （?）犛犖犜 疫苗或预防措施(商品名，若有Vaccineor prophylaxis (rand name, if appJ icable) 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章of supervising c1inician Official stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No ofvaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用)Duration of protection (if applicable) E 疫苗或预防措施(商品名，若有Vaccincor prophylaxis (Brand name, if applicabJe) 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章ofsupervising c1inician Official stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用)Duration of protection (if applicable) P 犽）? ?犾）? ?犃 （?）犛犖犜 疫苗或预防措施(商品名，若有Vaccineor prophylaxis (Brand name, if applicable) 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章of supervising clinician Official stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用)Duration of protection ( if applicable) i豆疫苗或预防措施(商品名，若有Vaccineor prophylaxis (Brand name, if applicable) 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章of supervising clinician Official stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用)Duration of protection (if applicable) g 犿）? ?狀）? ?犃 （?） 犛犖犜 疫苗或预防措施(商品名，若有Vaccineor prophylaxis (Brand nam e, if appl icabl e) 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章。fsupervising c1inician Official stamp of 疫苗或预防措施生产广商及批号admini stering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用)Duration of protection (if applicable) 哇。疫苗或预防措施(商品名，若有Vaccineor prophylaxis (Brand name, if applicable) 日期Date监督执行医师签名和专业情况S ignature and professional status 施种机构的印章of supervising clinician Official stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用)Duration of protection (if applicable) 吐11狅）? ?狆）? ?犃 （?） 犛犖犜 疫苗或预防措施(商品名，若有Yaccineor prophylaxis (Brand nam e. if appl icable ) 日期Date监督执行医师签名和专业情况S ignature and professional status 施种机构的印章of supervising clinician Official stamp of 疫苗或预防措施生产厂商及批号adminis ter ing center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用)Duration of protection (if applicable) U 疫苗或预防措施(商品名，若有Yaccineor prophylax is (Brand nam e. if applicable) 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章of supervising clinician Of ficial stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期若适用Duration of protection (if applicable) 13 狇）? ?狉）? ?狊）? ?犃 （?） 犛犖犜 疫苗或预防措施(商品名，若有Vaccineor prophylaxis (Brand name, if applicable) 日期Date监督执行医师签名和专业情况Signature and professional status 施种机构的印章of supervising clinician Official stamp of 疫苗或预防措施生产厂商及批号administering center Manufacturer and batch No of vaccine or prophylaxis 接种剂量和使用方法Vaccination does and route 疫苗保护期(若适用)Duration ofprotection (ifapplicable) 1呈xxxx (防伪标识)狋）?犃 （?） 犛犖犜 犃 ? 。?犃 ? 犛犖犜 编号/No:210001051112010526 蹦蘸撬摇摇罐罐罐鳝罐罐罐服罐麟榻黯鳞罐罐罐擦鞋鳝鑫罐望王东强WANG DONG QIANG xxx 111 根据国际卫生条例.在指明的日期接种了疫苗或接受了预防措施以防止=黄热病疫苗Has on the date indicated been vaccinated or received prophylaxis against (name of disease or condition) Yellow Fever in accordance with the International Health Regulations 日期Date2015年8月31日/ 31 Aug. 2015 监督执行医师签名和专业情况xxx 临床医学Signature and professional status xxx Cllnical medicine 施种机构的印章of supervising c1inician Official stamp of administering center 疫苗或预防措施生产厂商及批号北京天坛生物刷品有限公司Manufacturer and batch No BEIJING TlANTAN xxx of vaccine or prophylaxis BIOLOGICAL PRODUCT CO.,LTD. 20131004 证书有效期从2015年9月10日至2025年9月9日Certificate valid from 10 Sep.2015 until 09 Sep.2025 2 ?犃 （?） 犛犖犜 其他预防接种或预防措施证明CERTIFICATE OF OTHER VACCINATION OR PROPHYLAXIS 疫苗或预防措施(商品名，若有Vaccineor prophylaxis (Brand name, if applicable) 乙肝(安在时)Hepatitis B (Engerix B) 日期OaLc2014年9月15日/ 15 Sep.2014 监督执行医师签名和专业情况xxx 临床医学施种机构的印章Signature and professional status xxx Clinical medicine Official stamp 01 of supervising c1inician administering ccnter 疫苗或预防措施生产厂商及批号葛兰素史克中国)有限公司Manufacturer and batch No GSK ofvaccine or prophylaxis YHBVC464AB xxx 接种剂量和使用方法1.0 mL肌肉注射Vaccination does and route 1M 疫苗保护期(若适用)Duration of protection (if applicable) ?犅（?）?犅 ? 。?犆犈犚犜 犐 犉 犐 犆犃犜犈犗犉犆犗犖犜犚犃 犐 犖犇 犐 犆犃犜 犐 犗犖犜犗犞犃犆犆 犐 犖犃犜 犐 犗犖犗犚犘犚犗犘犎犢犔犃犡 犐 犛犈狀 狋 狉 狔 犈狓 犻 狋犐 狀 狊 狆 犲 犮 狋 犻 狅 狀犪 狀 犱犙狌 犪 狉 犪 狀 狋 犻 狀 犲狅 犳犘 犚 犆犺 犻 狀 犪?犅 ? 犛犖犜 编号No.姓名性别口男Male口女FemaleName Sex 出生日期国籍Date of birth Nationality 护照或身份证号Passportor ID. number tt证明该人员因下遮医学原因，不适合接种(疾病名称)疫苗，I 或不适合采取预防措施。This is to certi付出atimmunization or prophyl阻isagainst (Name of disease) for由eperson described above is medically contraindicated because of the岛Ilowingconditions 医师签字签发单位的印章曰期Signa阳reof clinician Official stamp of administering centre Date 犅 ? 。?犆犈犚犜 犐 犉 犐 犆犃犜犈犗犉犆犗犖犜犚犃 犐 犖犇 犐 犆犃犜 犐 犗犖犜犗犞犃犆犆 犐 犖犃犜 犐 犗犖犗犚犘犚犗犘犎犢犔犃犡 犐 犛犈狀 狋 狉 狔 犈狓 犻 狋犐 狀 狊 狆 犲 犮 狋 犻 狅 狀犪 狀 犱犙狌 犪 狉 犪 狀 狋 犻 狀 犲狅 犳犘 犚 犆犺 犻 狀 犪?犅 ? 犛犖犜 编号No.210001051112 0526 姓名王东强性别团男Male口文FemaleName W ANG OONG QIANG Sex 出生日期国籍中国1985年8月15日/15Aug.1985 Oate of birth Nationality Chinese 护照或身份证号xxxxxxxxxxxxx Passport or 10. number 兹证明该人员因下边医学原因鸡蛋过敏，不适合接种(疾病名称)黄热病疫苗，或不适合采取预防措施.This is to ce由专ythat immunization or prophylaxis against (Name of disease) Yellow Fever for the person described above is medically contraindicated because of the following conditions He is allergic to eggs 医师签字xxx 签发单位的印章xxx 曰期2015年9月15日Signatnre of clinician xxx Official st田npof administering centre Date 15 Sep.2015 ?犆（?）?犆 ? 。?；?，?、?；?“? ”?。?，? ?，? ?。?犆 ? 犛犖犜 预防接种转卡记录Record Transcribed from Vaccination History 本记录转抄自以下人员的既往预防接种卡This record is transcribed from the foIlowing persons previous vaccination history 姓名/Name国籍/Nationality性别/Sex口男Male口女Female护照或身份证号码/Passportor ID. Number 出生日期/Dateofbirth Cday, month, year) / 疫苗/Vaccine|接种时间/Date ofvaccination (d町，month, year) 医师签字签发单位的印章日期Signature of Clinician Official Stamp of Administering Centre Date ?犆 （?） 犛犖犜 疫苗IVaccine|接种时间/Date ofvaccination (day, month, year) 以下空白IThe following is intentionally left blank 医师签字签发单位的印章日期Signature of Clinician Official Stamp of Administering Centre Date = 犆 ? 。?犆 ? 犛犖犜 预防接种转卡记录Record Transcribed from Vaccination History 本记录转抄自以下人员的既往预防接种卡This record is transcribed from the following persons previous vaccination history 姓名/Name王牵强WANGDONG OIANG 国籍/Nationality中国CHINESE性别ISex团男Male口女Female护照或身份证号码lPassportor ID. Number XXXXXXXXXXX 出生日期lDateofbirth (day, month, year) 1996年1lJlH日114Dec.1996 疫苗IVaccine|接种时间/Date of vaccination (d町，month, year) 乙肝Hep.B14 Dec. 1996 16 Jan. 1997 15 Jun. 1997 卡介苗BCG15 Dec. 1996 脊髓灰质炎Polio14 Feb. 1997 14 Mar. 1997 15 Apr. 1997 08 Jun. 1998 16 Dec. 2000 百臼破DTP14 Mar. 1997 15 Apr. 1997 15 May 1997 08 Jun. 1998 麻莎Measles14 Aug. 1997 医师签字xxx 签发单位的印章xxx日期2015年8月31日Signature ofClinician XXX Official Stamp of Administering Centre Date 31 Aug. 2015 z ?犆 （?） 犛犖犜