FORMS FOR IMMUNISATION ġ 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 ġ S.L.36.29 FORMS FOR IMMUNISATION
SCHEDULE
(Regulation 2)
Form No. 1
ĊERTIFIKAT TA’ TILQIM
CERTIFICATE OF VACCINATION
Jiena, hewn taħt iffirmat, niċċertifika li .....................................
I, the undersigned, hereby certify that
iben/bint .............................. imwieled/a ............ fi ..................
the son/daughter of born at   on
u li joqgħod/toqgħod ................................................................
and residing at
ġie/t imlaqqam/a minni kontra d-Difterite, Tetnu u Poljomijelite
kif ġej:
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 DOŻA  ISEM IT-TABIB
TYPE OF 
VACCINE
DATE DOSE NAME OF 
MEDICAL 
PRACTITIONER
L-ewwel doża .................... ................. ................. ...........................
First dose .................... ................. ................. ...........................
It-tieni doża .................... ................. ................. ...........................
Second dose .................... ................ ................ ...........................
It-tielet doża .................... ................. ................. ...........................
Third dose .................... ................. ................. ...........................
Dożi Booster .................... ................. ................. ...........................
Booster doses .................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
.................... ................. ................. ...........................
FORMS FOR IMMUNISATION ġ S.L.36.29 3
Form No. 2
ĊERTIFIKAT LI TILQIMA TĦALLIET GĦAL DARB’OĦRA
CERTIFICATE OF POSTPONEMENT
Jiena, hewn taħt iffirmat, b’dan niċċertifika li fil-fehma tiegħi
...................................... 
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 joqgħod/toqgħod .......................................... mhux fi stat li
and residing at 
jitlaqqam/titlaqqam kontra d-Difterite, Tetnu u Poljomijelite, u
għalhekk qed inħalli dan għal darb’oħra. 
in a fit and proper state to be immunized against Diphtheria,
Tetanus and   Poliomyelitis, and   I do hereby postpone the
immunization.
It-tarbija għandha terġa’ tinġieb 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 għalqet is-sena, dan iċ-ċertifikat
għandu jiġi approvat minn uffiċjal mediku tas-saħħa.
NOTE: When child is over one year, this certificate must be
approved by a medical officer of health.
4 ġ S.L.36.29 FORMS FOR IMMUNISATION
Form No. 3
AVVIŻ LlLL-ĠENITURI 
NOTICE TO PARENTS
Jiena, hawn taħt iffirmat, navżak li għandek tlaqqam it-tarbija
(1) ................................
I, the undersigned, hereby give you notice to have the child (1)
.............................. li t-twelid tagħha issa huwa reġistrat, kontra
d-Difterite, Tetnu u  Poljomijelite malli tagħlaq it-tliet xhur, skond
id-disposizzjonijiet ta’ l-Ordinanza dwar it-Tħaris mill-Mard u
jekk tonqos milli tagħmel hekk tista’ teħel il-penalitajiet stabbiliti
bil-liġi.
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)
Uffiċjal Anzjan tal-Pulizija inkarigat mid-Distrett ta’ ............
Senior Police Officer in charge of District.
(1) Niżżel l-Isem 
(1) Insert Name
FORMS FOR IMMUNISATION ġ S.L.36.29 5
ORDINANZA DWAR IT-TĦARIS MILL-MARD
Tifsir
Il-ġenituri, jew kull persuna oħra li jkollha taħt il-kura tagħha
tarbija ta’ iżjed minn tliet xhur, u li mhix imlaqqma kif għandha
tkun kontra d-Difterite, it-Tetnu u l-Poljomijelite għandhom jieħdu
din it-tarbija f’Ċentru tat-Tilqim fil-Furjana jew ir-Rabat,
Għawdex, biex tiġi mlaqqma u għandhom jerġgħu jieħdu t-tarbija
għal aktar dożi skond kif jiġu mitluba mill-uffiċjal inkarigat minn
dan iċ-Ċentru.
Jekk it-tarbija ma tkunx fi stat li tista’ titlaqqam il-ġenituri jew
persuna oħra għandhom jieħdu ċertifikat minghand it-tabib taċ-
ċentru tat-tilqim fejn hemm imfisser din iċ-ċirkostanza, u
għandhom jerġgħu jieħdu t-tarbija fid-data li tiġi ndikata fuq 1-
istess ċertifikat. Meta t-tarbija tkun għalqet sena dan iċ-ċertifikat
għandu jiġi kkonfermat mill-uffiċjal mediku tas-saħħa.
II-missier jew l-omm jew kull persuna oħra bħalma hu msemmi
hawn fuq jistgħu jieħdu t-tarbija biex titlaqqam għand tabib privat.
F’dawn il-każi t-tabib privat għandu jagħti ċertifikat tat-tilqima/
tħollija għal darb’oħra, skond il-liġi.
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.
