FORMS FOR IMMUNISATION [ 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 [ S.L.36.29 FORMS FOR IMMUNISATION
SCHEDULE
(Regulation 2)
Form No. 1
~ERTIFIKAT TA’ TILQIM
CERTIFICATE OF VACCINATION
Jiena, hewn ta]t iffirmat, ni``ertifika li .....................................
I, the undersigned, hereby certify that
iben/bint .............................. imwieled/a ............ fi ..................
the son/daughter of born at   on
u li joqg]od/toqg]od ................................................................
and residing at
[ie/t imlaqqam/a minni kontra d-Difterite, Tetnu u Poljomijelite
kif [ej:
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|A  ISEM IT-TABIB
TYPE OF 
VACCINE
DATE DOSE NAME OF 
MEDICAL 
PRACTITIONER
L-ewwel do\a .................... ................. ................. ...........................
First dose .................... ................. ................. ...........................
It-tieni do\a .................... ................. ................. ...........................
Second dose .................... ................ ................ ...........................
It-tielet do\a .................... ................. ................. ...........................
Third dose .................... ................. ................. ...........................
Do\i Booster .................... ................. ................. ...........................
Booster doses .................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
FORMS FOR IMMUNISATION [ S.L.36.29 3
Form No. 2
~ERTIFIKAT LI TILQIMA T}ALLIET G}AL DARB’O}RA
CERTIFICATE OF POSTPONEMENT
Jiena, hewn ta]t iffirmat, b’dan ni``ertifika li fil-fehma tieg]i
...................................... 
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]od/toqg]od .......................................... mhux fi stat li
and residing at 
jitlaqqam/titlaqqam kontra d-Difterite, Tetnu u Poljomijelite, u
g]alhekk qed in]alli dan g]al darb’o]ra. 
in a fit and proper state to be immunized against Diphtheria,
Tetanus and   Poliomyelitis, and   I do hereby postpone the
immunization.
It-tarbija g]andha ter[a’ tin[ieb 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]alqet is-sena, dan i`-`ertifikat
g]andu ji[i approvat minn uffi`jal mediku tas-sa]]a.
NOTE: When child is over one year, this certificate must be
approved by a medical officer of health.
4 [ S.L.36.29 FORMS FOR IMMUNISATION
Form No. 3
AVVI| LlLL-{ENITURI 
NOTICE TO PARENTS
Jiena, hawn ta]t iffirmat, nav\ak li g]andek tlaqqam it-tarbija
(1) ................................
I, the undersigned, hereby give you notice to have the child (1)
.............................. li t-twelid tag]ha issa huwa re[istrat, kontra
d-Difterite, Tetnu u  Poljomijelite malli tag]laq it-tliet xhur, skond
id-disposizzjonijiet ta’ l-Ordinanza dwar it-T]aris mill-Mard u
jekk tonqos milli tag]mel hekk tista’ te]el il-penalitajiet stabbiliti
bil-li[i.
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`jal Anzjan tal-Pulizija inkarigat mid-Distrett ta’ ............
Senior Police Officer in charge of District.
(1) Ni\\el l-Isem 
(1) Insert Name
FORMS FOR IMMUNISATION [ S.L.36.29 5
ORDINANZA DWAR IT-T}ARIS MILL-MARD
Tifsir
Il-[enituri, jew kull persuna o]ra li jkollha ta]t il-kura tag]ha
tarbija ta’ i\jed minn tliet xhur, u li mhix imlaqqma kif g]andha
tkun kontra d-Difterite, it-Tetnu u l-Poljomijelite g]andhom jie]du
din it-tarbija f’~entru tat-Tilqim fil-Furjana jew ir-Rabat,
G]awdex, biex ti[i mlaqqma u g]andhom jer[g]u jie]du t-tarbija
g]al aktar do\i skond kif ji[u mitluba mill-uffi`jal inkarigat minn
dan i`-~entru.
Jekk it-tarbija ma tkunx fi stat li tista’ titlaqqam il-[enituri jew
persuna o]ra g]andhom jie]du `ertifikat minghand it-tabib ta`-
`entru tat-tilqim fejn hemm imfisser din i`-`irkostanza, u
g]andhom jer[g]u jie]du t-tarbija fid-data li ti[i ndikata fuq 1-
istess `ertifikat. Meta t-tarbija tkun g]alqet sena dan i`-`ertifikat
g]andu ji[i kkonfermat mill-uffi`jal mediku tas-sa]]a.
II-missier jew l-omm jew kull persuna o]ra b]alma hu msemmi
hawn fuq jistg]u jie]du t-tarbija biex titlaqqam g]and tabib privat.
F’dawn il-ka\i t-tabib privat g]andu jag]ti `ertifikat tat-tilqima/
t]ollija g]al darb’o]ra, skond il-li[i.
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.
