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 taht iffirmat, niccertifika li .....................................
I, the undersigned, hereby certify that
iben/bint .............................. imwieled/a ............ fi ..................
the son/daughter of born at   on
u li joqghod/toqghod ................................................................
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 DOZA  ISEM IT-TABIB
TYPE OF 
VACCINE
DATE DOSE NAME OF 
MEDICAL 
PRACTITIONER
L-ewwel doza .................... ................. ................. ...........................
First dose .................... ................. ................. ...........................
It-tieni doza .................... ................. ................. ...........................
Second dose .................... ................ ................ ...........................
It-tielet doza .................... ................. ................. ...........................
Third dose .................... ................. ................. ...........................
Dozi Booster .................... ................. ................. ...........................
Booster doses .................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
FORMS FOR IMMUNISATION g S.L.36.29 3
Form No. 2
CERTIFIKAT LI TILQIMA THALLIET GHAL DARB’OHRA
CERTIFICATE OF POSTPONEMENT
Jiena, hewn taht iffirmat, b’dan niccertifika li fil-fehma tieghi
...................................... 
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 joqghod/toqghod .......................................... mhux fi stat li
and residing at 
jitlaqqam/titlaqqam kontra d-Difterite, Tetnu u Poljomijelite, u
ghalhekk qed inhalli dan ghal darb’ohra. 
in a fit and proper state to be immunized against Diphtheria,
Tetanus and   Poliomyelitis, and   I do hereby postpone the
immunization.
It-tarbija ghandha terga’ tingieb 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 ghalqet is-sena, dan ic-certifikat
ghandu jigi approvat minn ufficjal mediku tas-sahha.
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
AVVIZ LlLL-GENITURI 
NOTICE TO PARENTS
Jiena, hawn taht iffirmat, navzak li ghandek tlaqqam it-tarbija
(1) ................................
I, the undersigned, hereby give you notice to have the child (1)
.............................. li t-twelid taghha issa huwa registrat, kontra
d-Difterite, Tetnu u  Poljomijelite malli taghlaq it-tliet xhur, skond
id-disposizzjonijiet ta’ l-Ordinanza dwar it-Tharis mill-Mard u
jekk tonqos milli taghmel hekk tista’ tehel il-penalitajiet stabbiliti
bil-ligi.
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)
Ufficjal Anzjan tal-Pulizija inkarigat mid-Distrett ta’ ............
Senior Police Officer in charge of District.
(1) Nizzel l-Isem 
(1) Insert Name
FORMS FOR IMMUNISATION g S.L.36.29 5
ORDINANZA DWAR IT-THARIS MILL-MARD
Tifsir
Il-genituri, jew kull persuna ohra li jkollha taht il-kura taghha
tarbija ta’ izjed minn tliet xhur, u li mhix imlaqqma kif ghandha
tkun kontra d-Difterite, it-Tetnu u l-Poljomijelite ghandhom jiehdu
din it-tarbija f’Centru tat-Tilqim fil-Furjana jew ir-Rabat,
Ghawdex, biex tigi mlaqqma u ghandhom jergghu jiehdu t-tarbija
ghal aktar dozi skond kif jigu mitluba mill-ufficjal inkarigat minn
dan ic-Centru.
Jekk it-tarbija ma tkunx fi stat li tista’ titlaqqam il-genituri jew
persuna ohra ghandhom jiehdu certifikat minghand it-tabib tac-
centru tat-tilqim fejn hemm imfisser din ic-cirkostanza, u
ghandhom jergghu jiehdu t-tarbija fid-data li tigi ndikata fuq 1-
istess certifikat. Meta t-tarbija tkun ghalqet sena dan ic-certifikat
ghandu jigi kkonfermat mill-ufficjal mediku tas-sahha.
II-missier jew l-omm jew kull persuna ohra bhalma hu msemmi
hawn fuq jistghu jiehdu t-tarbija biex titlaqqam ghand tabib privat.
F’dawn il-kazi t-tabib privat ghandu jaghti certifikat tat-tilqima/
thollija ghal darb’ohra, skond il-ligi.
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.
