FORMS FOR IMMUNISATION _g S.L.36.29 1
SUBSIDIARY LEGISLATION 36.29
FORMS FOR IMMUNISATION REGULATIONS
25th May, 1992
LEGAL NOTICE 28 of 1982.
Title.
Regulations.
Forms. 
Cap. 36.
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.
(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.
2 _g S.L.36.29 FORMS FOR IMMUNISATION
SCHEDULE
(Regulation 2)
Form No. 1
_CERTIFIKAT TA’ TILQIM
CERTIFICATE OF VACCINATION
Jiena, hewn ta_ht iffirmat, ni_c_certifika li .....................................
I, the undersigned, hereby certify that
iben/bint .............................. imwieled/a ............ fi ..................
the son/daughter of born at   on
u li joqg_hod/toqg_hod ................................................................
and residing at
_gie/t imlaqqam/a minni kontra d-Difterite, Tetnu u Poljomijelite
kif _gej:
has been immunized by me against Diphtheria, Tetanus, and
Poliomyelitis as follows: 
.............................................
Firma tat-Tabib
Signature of Medical Practitioner
Isem u Indirizz (ITTRI KAPITALI) ..............................................
Name and Address (IN BLOCK LETTERS)
.....................................................................................................
Data .................................... 
Date
XORTA TA’ 
TILQIM
DATA DO_ZA  ISEM IT-TABIB
TYPE OF 
VACCINE
DATE DOSE NAME OF 
MEDICAL 
PRACTITIONER
L-ewwel do_za .................... ................. ................. ...........................
First dose .................... ................. ................. ...........................
It-tieni do_za .................... ................. ................. ...........................
Second dose .................... ................ ................ ...........................
It-tielet do_za .................... ................. ................. ...........................
Third dose .................... ................. ................. ...........................
Do_zi Booster .................... ................. ................. ...........................
Booster doses .................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
FORMS FOR IMMUNISATION _g S.L.36.29 3
Form No. 2
_CERTIFIKAT LI TILQIMA T_HALLIET G_HAL DARB’O_HRA
CERTIFICATE OF POSTPONEMENT
Jiena, hewn ta_ht iffirmat, b’dan ni_c_certifika li fil-fehma tieg_hi
...................................... 
I, the undersigned, hereby certify that I am of the opinion that
iben/bint ...................... imwieled/a ..................... fi ..................
the son/daughter of born at 
u li joqg_hod/toqg_hod .......................................... mhux fi stat li
and residing at 
jitlaqqam/titlaqqam kontra d-Difterite, Tetnu u Poljomijelite, u
g_halhekk qed in_halli dan g_hal darb’o_hra. 
in a fit and proper state to be immunized against Diphtheria,
Tetanus and   Poliomyelitis, and   I do hereby postpone the
immunization.
It-tarbija g_handha ter_ga’ tin_gieb 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_halqet is-sena, dan i_c-_certifikat
g_handu ji_gi approvat minn uffi_cjal mediku tas-sa_h_ha.
NOTE: When child is over one year, this certificate must be
approved by a medical officer of health.
4 _g S.L.36.29 FORMS FOR IMMUNISATION
Form No. 3
AVVI_Z LlLL-_GENITURI 
NOTICE TO PARENTS
Jiena, hawn ta_ht iffirmat, nav_zak li g_handek tlaqqam it-tarbija
(1) ................................
I, the undersigned, hereby give you notice to have the child (1)
.............................. li t-twelid tag_hha issa huwa re_gistrat, kontra
d-Difterite, Tetnu u  Poljomijelite malli tag_hlaq it-tliet xhur, skond
id-disposizzjonijiet ta’ l-Ordinanza dwar it-T_haris mill-Mard u
jekk tonqos milli tag_hmel hekk tista’ te_hel il-penalitajiet stabbiliti
bil-li_gi.
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_cjal Anzjan tal-Pulizija inkarigat mid-Distrett ta’ ............
Senior Police Officer in charge of District.
(1) Ni_z_zel l-Isem 
(1) Insert Name
FORMS FOR IMMUNISATION _g S.L.36.29 5
ORDINANZA DWAR IT-T_HARIS MILL-MARD
Tifsir
Il-_genituri, jew kull persuna o_hra li jkollha ta_ht il-kura tag_hha
tarbija ta’ i_zjed minn tliet xhur, u li mhix imlaqqma kif g_handha
tkun kontra d-Difterite, it-Tetnu u l-Poljomijelite g_handhom jie_hdu
din it-tarbija f’_Centru tat-Tilqim fil-Furjana jew ir-Rabat,
G_hawdex, biex ti_gi mlaqqma u g_handhom jer_gg_hu jie_hdu t-tarbija
g_hal aktar do_zi skond kif ji_gu mitluba mill-uffi_cjal inkarigat minn
dan i_c-_Centru.
Jekk it-tarbija ma tkunx fi stat li tista’ titlaqqam il-_genituri jew
persuna o_hra g_handhom jie_hdu _certifikat minghand it-tabib ta_c-
_centru tat-tilqim fejn hemm imfisser din i_c-_cirkostanza, u
g_handhom jer_gg_hu jie_hdu t-tarbija fid-data li ti_gi ndikata fuq 1-
istess _certifikat. Meta t-tarbija tkun g_halqet sena dan i_c-_certifikat
g_handu ji_gi kkonfermat mill-uffi_cjal mediku tas-sa_h_ha.
II-missier jew l-omm jew kull persuna o_hra b_halma hu msemmi
hawn fuq jistg_hu jie_hdu t-tarbija biex titlaqqam g_hand tabib privat.
F’dawn il-ka_zi t-tabib privat g_handu jag_hti _certifikat tat-tilqima/
t_hollija g_hal darb’o_hra, skond il-li_gi.
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.
