范文一：预防接种证

附件2

(入托、入学必备)

Chongqing Immunization Record Indispensable to nursery and school

enrollment

重庆市卫生局

Chongqing Municipal

Health Bureau

区县 疾控中心 区县 疾控中心 万州区 璧山县 58155036 41407946 涪陵区 梁平县 72255332 53228820 渝中区 城口县 89035615 59909867 大渡口 丰都县 68927303 70714283 江北区 垫江县 89186302 74666162 沙坪坝 武隆县 65460567 77728921 九龙坡 忠县 89123971 54454806 南岸区 开县 62923007 52235720 北碚区 云阳县 68356342 85832206 万盛区 奉节县 48273396 56569955 双桥区 巫山县 43332568 57690924 渝北区 巫溪县 67195159 51528391 巴南区 石柱县 66215120 73335869 黔江区 秀山县 79925348 76683194 长寿区 酉阳县 40251810 75552191 綦江县 彭水县 48626482 78445385 潼南县 江津区 44559961 47564324 铜梁县 合川区 45689982 42733038 大足县 永川区 43768609 49801425 荣昌县 46787227 南川区 71648331

预防接种的有关规定

Rule for Immunization

1. 儿童出生后，请监护人尽快(1个月内)到户籍地接种单位办理领证手续，以便预防接种部门掌握儿童情况，安排合适的接种计划。 2. 每次接种时必须携带本证，并按预防接种通知单或预约日期及时到指定地点接种相应疫苗。医务人员凭证接种，每次接种后应在证上做接种记录。

3. 国家明确规定幼托机构、学校在办理入托、入学手续时，均要查验本证，必须妥善保管。如有损坏或遗失应及时到发证机构办理补证手续。无法出示本证者不得入托、入学。

4. 有些疫苗需按一定的间隔时间连续接种多次才有效，请一定按照免疫接种程序规定的接种日期进行预防接种，不要半途而废。 5. 医务人员上门调查预防接种工作时，请协助主动出示本证，配合查验。

6. 儿童免疫接种有一定的适应症，因此家长带孩子到接种门诊接种时要主动向接种人员提供您孩子的健康状况和以往有无对药物、疫苗过敏史，并有权询问哪些情况下不宜接种。必要时，接种人员在对儿童进行体检后再确定能否进行接种。

7. 接种单位:________________预防接种门诊

地址:__________________ _________;联系电话:____________;

接种时间:?每天:__:__,__:__; ?每月(周、旬)________________;

如果对预防接种过程有疑问，可以向接种单位的医生咨询或者各级疾病预防控制中心预防接种管理部门咨询，联系方式见下。

_______区县疾病预防控制中心，联系电话:

_______________

重庆市疾病预防控制中心网址:www.cqcdc.org

重庆市疾病预防控制中心免疫预防科:jmk@cqcdc.org

身份证号:_____________

IC卡编号(No.of IC)_____________

接种证编号(No.of Imm.card)_____________

儿童姓名(Name):______ 出生体重(Birth weight):____千克(Kg) 性别(Sex): 男(Male) 女(Female)

出生日期(DOB):______年____月____日____时

出生医院(Birth address):1 县级以上 2 乡级 3 村级 4家中 现住地址(Present address):_________区/县________________; 户口地址(Registered address):__________________________; 属性: 本市(Local); 外来(Migratory)

移动电话(Mobile phone):

家庭电话(Home phone):

备用电话(Alternative phone):_________________________ 电子邮箱(E-mail): _________________________ 父亲姓名(Father name):_________工作单位(Work Unit):______ 身份证号码(ID code):

母亲姓名(Mother name):_________工作单位(Work Unit):______ 身份证号码(ID code):

母亲乙肝标志物(Hepatitis B indicators for mother):

HBsAg( 阳性，; 阴性,); HBeAg( 阳性，; 阴性,);

发证单位(Authority of issue):____区/县______医院/乡镇卫生院 (签章)

发证日期(Date of issue):______年____月____日

为了保证预防接种安全，请接种对象/监护人阅读以下预防接种注意事项告知书的内容，在充分理解内容的基础上签名确认。如不理解，可向医生咨询。

预防接种注意事项告知书

Declaration of Consideration for Immunization

为了保证预防接种安全，接种对象/监护人必须首先知晓有关的注意事项。以下是预防接种前和预防接种后的注意事项，在每次预防接种时应进行对照，如果有符合本告知书注意事项的情况，或者有其他本告知书未提及但接种对象/监护人认为有可能影响预防接种安全的情况，必须事先告知医生。

预防接种前的注意事项:

有以下情况者暂缓进行预防接种，情况缓解或痊愈后再行接种:

, 接种部位有严重皮炎、牛皮癣、湿疹及化脓性皮肤病者;

, 发热,37.1?者(发热可能是流感、麻疹等急性传染病的早期症状，

此时接种可能会加重病情，并可能发生偶合事件);

, 每天排便次数超过4次者，暂缓服用脊灰疫苗(腹泻会使疫苗很快排

泄，失去作用;腹泻还可能为病毒所致，可能发生偶合事件)。

有以下情况者不宜进行预防接种:

, 有严重心肝肾疾病和结核病者(体质较差，患病器官不堪重负);

, 神经系统疾病者，如癫痫、脑发育不全;

, 重度营养不良、严重佝偻病、先天性免疫缺陷者(制造免疫力的原料

不够或形成免疫力的器官功能欠佳);

, 有哮喘、荨麻疹等过敏体质者(可能对疫苗的某些成分过敏);

, 罹患各种疫苗说明书中规定的禁忌症者。

预防接种后的注意事项:

, 预防接种后应多休息，多饮用开水，并注意注射局部的清洁，以防局

部感染。

, 接种后如果有发热、局部红肿疼痛等反应，应及时告知接种单位医生

做好对症处理。

, 极个别人可能会出现高热(,38.6?)或持续发热数日或出现其他

异常的反应，应及时去医院就诊，以防延误病情。并及时告知接种单

位医生做好相关记录。

接种对象/监护人如已充分理解上述告知内容，请在下面签名:

接种对象/监护人签名:________;签名日期:____年__月__日

重庆市第一类疫苗标准接种程序

Standard Schedule for Vaccines of First Group in Chongqing

乙肝 麻腮风 甲肝减毒活A+C流脑 脊灰 接种起始年龄 麻风 乙脑减毒疫苗 疫苗 疫苗 疫苗 卡介苗 百白破疫白破 A群流脑 疫苗 疫苗 Age begin to 疫苗 MMR HAV MACV 苗DPT BCG DT 疫苗MAV MRV EBV vaccinate OPV HBV

出生Birth ? ?

1月龄1month ?

2月龄2months ?

3月龄3months ? ?

4月龄4months ? ?

5月龄5months ?

6月龄6months ? ?

8月龄8months ? ?

9月龄9months ?

? 1.5岁

1.5岁,2岁 ? ? 1.5years,2 years

2岁2years ?

? 3岁3years

4岁4years ?

? 6岁6years ?

注:在疫苗更替阶段，麻风疫苗不足时可用麻疹疫苗替代，麻腮风疫苗不足时可用麻腮或麻疹疫苗替代

接种预约表Appointment for Immunization

出生日期(DOB):______年____月____日

如期接种 如期接种 疫苗中文 疫苗中文

预约日期 预约日期 Immunized Immunized 简称 简称

on date? on date? Vaccine name Vaccine name Appoint date Appoint date ab. ?是 ×否 ab. ?是 ×否

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接种记录(一)Immunization Record(Part 1)

接种日期 疫苗中文简称 接种单位 接种者 疫苗批号

Vaccine name ab. Lots Hospital Signature Date of given

/ / / 时 1 乙肝疫苗

(新生儿) 2 / /

HBV 3 / / 卡介苗

/ / BCG

1 / /

2 / / 脊灰疫苗

OPV 3 / /

4 / /

1 / /

2 / / 百白破

DPT 3 / /

4 / / 麻风疫苗

/ / MRV

麻腮风疫苗

/ / MMR

麻腮疫苗

/ / MMV

乙脑减毒 1 / /

疫苗

2 / / EBV

A群1 / /

流脑疫苗

2 / / MAV

A+C流脑 1 / /

疫苗

2 / / MACV

8

接种记录(二)Immunization Record(Part 2)

疫苗批号

接种日期 疫苗中文简称 接种单位 接种者 Vaccine name ab. Hospital Signature Date of given Lots

白破疫苗DT / /

甲肝减毒疫苗

/ / HAV

脊灰疫苗强免

/ / OPV Booster

/ /

/ /

/ /

/ / 麻疹疫苗强免

/ / MV Booster

/ /

1 / / 7价肺炎疫苗2 / / PCV-7 3 / /

4 / / 水痘疫苗VZV / / 23价肺炎疫苗

/ / PPV23

流感疫苗FLU / /

/ /

1 / / 甲肝灭活疫苗

HAV 2 / / 轮状病毒疫苗

/ / RVV

9

接种记录(三)Immunization Record(Part 3)

疫苗批号

疫苗中文简称 接种日期 接种单位 接种者

Hospital Signature Vaccine name ab. Date of given Lots

1 / /

甲乙肝疫苗

2 / /

HABV

3 / /

1 / /

2 / /

狂犬病疫苗

3 / / RAB

4 / /

5 / /

1 / /

2 / / HIB疫苗

HIB 3 / /

4 / /

/ /

/ /

/ /

/ /

/ /

/ /

/ / 10

疫苗名称中英文对照表

Vaccine Name Matching in Chinese/English

中文全称 中文简称 英语名称 英文简称

Chinese ab. English name English ab. Chinese name

卡介苗 卡介苗 Bacillus Chalmette Guerin Vaccine BCG

乙型肝炎疫苗 乙肝疫苗 Hepatitis B Vaccine HBV 脊髓灰质炎疫苗 脊灰疫苗 Oral Poliomyelitis Vaccine OPV

百日咳白喉破伤风联合疫苗 百白破疫苗 Diphtheria Pertussis Tetanus Vaccine DPT

麻疹疫苗 麻疹疫苗 Measles Vaccine MV 乙型脑炎减毒活疫苗 乙脑减毒疫苗 Encephalitis B Vaccine EBV A群流行性脑膜炎疫苗 A群流脑疫苗 Meningococcus A Vaccine MAV A+C群流行性脑膜炎疫苗 AC群流脑疫苗 Meningococcus A&C Vaccine MACV 白喉破伤风二联疫苗 白破疫苗 Diphtheria Tetanus Vaccine DT 麻疹腮腺炎风疹联合疫苗 麻腮风疫苗 Measles Mumps Rubella Vaccine MMR 麻疹腮腺炎联合疫苗 麻腮疫苗 Measles Mumps Vaccine MMV

甲型肝炎疫苗 甲肝疫苗 Hepatitis A Vaccine HAV 流感嗜血杆菌疫苗 Hib疫苗 Haemophilus Influenza B Vaccine HIB 甲型、乙型肝炎联合疫苗 甲乙肝疫苗 Hepatitis A&B Vaccine HABV 麻疹风疹联合疫苗 麻风疫苗 Measles Rubella Vaccine MRV

狂犬病疫苗 狂犬病疫苗 Rabies Vaccine RAB

水痘疫苗 水痘疫苗 Varicella Zoster Vaccine VZV

7 valented Pneumococcal Conjugate 7价肺炎球菌结合疫苗 7价肺炎疫苗 PCV-7 Vaccine

23价肺炎球菌疫苗 23价肺炎疫苗 23 valented Pneumococcal Vaccine PPV23 流行性感冒疫苗 流感疫苗 Influenza Vaccine FLU

轮状病毒疫苗 轮病疫苗 Rotavirus Vaccine RVV

注意:本对照表中的中文简称和英文简称可能是非标准的，仅供本接

种证对照使用。

Attention:The Chinese or English abbreviation of vaccine name

in table above maybe informal adapted in this Record only.

11

过敏史记录Record for Allergy

可能的过敏原 发生过敏日期 过敏症描述 记录日期

Symptom Date of record Allergen possible Date of onset

/ / / /

/ / / /

/ / / /

禁忌症记录Record for Contradiction

禁忌症描述 发生禁忌症日期 记录日期

Symptom Date of onset Date of record

/ / / /

/ / / /

/ / / /

预防接种后制品反应记录

Record for Vaccine Reaction Following Immunization

记录日期 制品名称 生产单位 批号 接种日期 反应描述 反应日期 Date of Vaccine Manufacturer Lots Date of given Date of onset Symptom record

/ / / / / /

/ / / / / /

/ / / / / /

疫苗可预防疾病发病记录

Record for Vaccine-preventable Disease

疾病名称 发病日期 诊治单位 记录日期

Disease Date of onset Clinic Date of record

/ / / /

/ / / /

/ / / / 12

重庆市第二类疫苗介绍

Introduction for Vaccines of Second Group

疫苗中文简称 推荐接种对象

Vaccine name ab. Recommended population 乙肝疫苗HBV 除新生儿以外的乙型肝炎易感人群* Hib疫苗HIB 2月龄,6岁儿童

轮病疫苗 RVV 2月龄,3岁儿童

7价肺炎结合疫苗

3月龄,5岁儿童

PCV-7

1周岁及以上易感人群 甲肝灭活疫苗HAV

水痘疫苗VZV 1周岁及以上易感人群

23价肺炎疫苗PPV23 2周岁以上高危人群

甲乙肝疫苗HABV 15周岁及以上易感人群

60岁及以上老年人;患有慢性病、体弱、免疫功能低下及其流感疫苗FLU 他推荐接种人群

1.任何可疑接触狂犬病毒者

狂犬病疫苗RAB 2.被动物咬伤、抓伤，皮肤或粘膜被舔者

3.在疫区有咬伤危险或接触病毒机会的工作人员

如果需要接种上述疫苗，可向接种单位医生咨询;在医生指导下严格按说

明书使用;

接种上述疫苗必须本着自主自愿、谁收益、谁付费的原则。

*新生儿接种的乙肝疫苗属于第一类疫苗。

13

《中华人民共和国传染病防治法》

第十五条明确规定:

国家实行有计划的预防接种制度。

国家对儿童实行预防接种证制度。

《中华人民共和国未成年人保护法》

第三十二条明确规定: 卫生部门和学校应当为未成年人提供必要的卫生保健条件，做好预防疾病工作。

凭证接种 妥善保管

14

附件3

编号 6岁 5岁 4岁 3岁 2岁 1岁 0岁

家长姓名

工作单位 重庆市儿童计划免疫接种卡

备 注

姓 名 性 别 出生 年 月 日 现住地址 户口地址 预约电话 手机 Email 传染

病史 禁忌症及过敏史

0岁 接百白破三联A群流脑 麻乙种乙肝疫苗 脊灰疫苗 卡疫苗 疫苗 风脑日介疫疫一二三一二三一二三一二期 苗 苗 苗 次 次 次 次 次 次 次 次 次 次 次 年 日 月

15

编号 0岁 1岁 2岁 3岁 4岁 5岁 6岁

1.5 1.5~2岁 2岁

3岁 4岁 6岁 推荐疫苗 岁

AC AC白麻 百 接甲 乙 群 脊 群破HIBHIBHIBHIB风 白 种肝 脑 流 灰 流二腮 破 疫疫疫疫日疫 疫 脑 疫 脑联疫 疫 苗 苗 苗 苗 期 苗 苗 疫 苗 疫疫苗 苗 苗 苗 苗

年

日 月

推荐疫苗

237 甲接水 轮 流价价乙种痘 状 感肺肺肝 日疫 疫 疫炎炎疫期 苗 苗 苗 疫疫苗 苗 苗

年 日 月

16

范文二：预防接种证-英文

Shenyang Immunization Scraping the coat, input the code to inquire true and false Notice For China Mobile, sending short Record message 9500024 to inquire Shenyang Center for Disease Control and Prevention Supervised by Liaoning Anti-fake Center

Vaccines uniformly provided by Shenyang Center for

Diseases Control and Prevention are pasted with

special supply identification, and please check in the

process of vaccination.

Vaccinate by the Certificate, Safekeeping

This certificate is uniformly made by Shenyang Shenyang Center for Disease Control

Center for Disease Control and Prevention, and is and Prevention distributed for free.

Bacillus Calmette Guerin vaccine has been vaccinated,

the infant shall be reviewed on the first Monday when the

infant was born for 4 months Guide to Parents 1. According to the regulations of Article XII of “Law on the

Prevention and Control of Infectious Diseases of People’s No.: SZ-0504 Republic of China” and “The State Implements Immunization Certificate System”, our city will uniformly use Shenyang Name of Child: Qianhao Yu Sex: Male Immunization Record. 2. Immunization record is the effective proof for children to Date of Birth: March 15, 2005 Weight of Birth: 3,500g receive vaccination according to the law. When the newborn is born, the parents or guardians shall timely apply to transact the immunization procedures to the delivery unit or immunization Address: medial health unit.

3. For each immunization of the children, the parents or guardians Residence Address: County / District Street / Village shall hold this certificate to vaccinate for children in designated location, vaccination outpatient clinic, vaccination station, or Place of Work / School Tel: village health center. 4. Children can enroll in a nursery, kindergarten, school, or going abroad by this certificate. If the children do not have this Juveniles who are under the age of 16 should fill the following information certificate or do not vaccinate according to this certificate, they must re-register this certificate and re-vaccinate, otherwise the Parents’ name: father: Zhiqun Yu Mother: Jing Lu formalities will not be transacted

5. When the household registrations of the children are migrated Working Unit: Farther Mother or live in new regions away from home, the parents or guardians shall hold this certificate to transact the immigration formalities in the designated location, vaccination outpatient Telephone No.: Farther Mother clinic, vaccination station, or village health center, and returning to the place original residence to transact the Date of removal: Year Month Day emigration formalities 6. This certificate shall be kept well. If the certificate is damaged or lost, the parents or guardians shall apply re-issuance to the Address of removal County / District local region or or village health center. 7. After vaccination, the children may have slight fever, local pain Whether insurance or not or red and swollen, which are the normal reaction and can fade within 3 days. If there are abnormal conditions after Date of issue: March 25, 2005 vaccination, please timely report to the vaccination unit and go

to medical unit to receive symptomatic treatment 8. When the relevant departments examine the vaccination work, The issuing Authority (Seal): Shenyang Huanggu Central Hospital the parents or guardians shall show this certificate for inspection.

When the infant was born for a month, two or Shenyang Center for Disease Control and Prevention

three hepatitis B vaccines shall be injected on Tuesday or Thursday of the first week at outpatient clinic of registered residence’s location.

Vaccination Public Board

Diseases that can Name of vaccines Vaccinated population Price of vaccination prevents

Bacillus Calmette Guerin vaccine Tuberculosis Newborn Free

Free Hepatitis B vaccine(5ug) Hepatitis B Newborn 0, 1 and 6 months

Free2, 3, 4 months, 1.5 – 2 years old, Poliomyelitis vaccine Poliomyelitis 4 years old

Free8 months, 1.5-2 years old, 6 Measles Attenuated Live Vaccine Measles years old

Pertussis, diphtheria, Free, acellular pertussis Pertussis-Diphtheria-Tetanus triple tetanus 3, 4, 5months, 1.5-2 years old diphtheria tetanus vaccine shall vaccine be paid. Tetanus-diphtheria Combined Vaccine Diphtheria, tetanus 6 years old Free

2 vaccinations at early period of 6 months - 1.5 years old are no Free, but Vero cells epidemic Epidemic encephalitis B vaccine Epidemic encephalitis B need; separately intensify once encephalitis B shall be paid. at 2 years old and 6 years old Group A Meningococcal Epidemic cerebrospinal Separately vaccinate once at 1, Free polysaccharide vaccine meningitis (Group A) 2, 4 and 6 years old Group A+C Meningococcal Epidemic cerebrospinal Above 2 years old Self-pay (including insurance) polysaccharide vaccine meningitis (Group A+C)

Self-pay Hepatitis B vaccine(10ug) Hepatitis B All the population

Newborn, accidentally infected Self-pay Hepatitis B hyper-immune globulin Hepatitis B population, pregnant of hepatitis B virus carrier

Self-pay Hepatitis A vaccine Hepatitis A Above 1 years old

Adult / 6-13 years old / 2-5 Self-pay Live Attenuated Varicella vaccine Varicella, herpes zoster years old children

Children pneumonia, Self-payHaemophilus Influenzae type B meningitis caused by 2 months - 5 years old vaccine Haemophilus Influenzae type B, etc.

Vaccinate 3 times for 6 months Self-pay old (2 months, 3 months and 4 Pneumonia, meningitis, 23-valent pneumococcal months); vaccinate 2 times for 6 otitis media, etc. caused polysaccharide vaccine months old - 1 year old; by pneumococcus vaccinate once for 1 year old to 5 years old

Influenza, etc. caused by Self-pay Vaccine by lysis of influenza virus Vaccinate once at 5 years old influenza virus

Self-payInfluenza vaccine cleavage vaccine Measles, rubella, mumps Above 2 years old

Self-pay Measles and rubella bivalent vaccine Measles, rubella Above 6 months old

Self-payMeasles, mumps bivalent vaccine Measles, mumps Above 1 years old

Self-payAttenuated live rubella vaccine Rubella Above 1 years old Bivalent live vaccine capsule of Self-pay Bacillary dysentery Above 8 months old dysentery

Infantile rotavirus Self-payLive oral rotavirus vaccine Above 1 years old diarrhea

Notes: The charge vaccines uniformly distributed by Shenyang Center for Disease Control and Prevention are pasted with uniform mark, persons who are vaccinated should pay attention to check. The injection cost is RMB 2.0 (LJF (2003) No. 35), and RMB 0.9 will be collected for self-destruction syringe if needed.

Informed Consent Form for Vaccination Program Immune Vaccine

Category of Contraindication Reaction

Vaccines

Hepatitis B vaccine Persons who suffer from hepatitis, fever, acute or Slight reaction, a few people will have

chronic disease, serious skin eczema, preterm low blush and induration in the position of

body weight, serious viscera deformity and allergic vaccine injection, and will fade away

history are forbidden to use this vaccine. in 2-3 days. There is generally no

whole body reaction, and very few

persons will appear chilly or low fever,

and individual is reported to have

urticarial.

Poliomyelitis 1. Persons who have immunodeficiency or are in the Only very few infants will have vaccine period of accepting the therapy of transient diarrhea after being

immunosuppressant is forbidden to get vaccinated. vaccinated, and will self-cure.

2. Persons who are allergic to milk or milk products

are forbidden to get vaccinated.

3. Persons who have fever or diarrhea (defecate

more than 4 times a day) or suffer from acute

infectious disease is forbidden to get vaccinated.

Measles vaccine Persons who have serious diseases, fever or allergic There is no reaction in partial body

history (especially who are allergic to eggs) are after rejection. A few persons may

forbidden to get vaccinated. have fever, and generally will not

exceed 2 days, and someone will have

sporadic rash.

Pertussis-diphtheria-1. Persons who have epilepsy, nervous system 1. Local part may appear red, pain and

tetanus triple disease or convulsions history are forbidden to get tickle or low fever, fatigue, headache,

vaccine vaccinated. etc. Generally, there is no need of

2. Persons who have acute infectious disease special treatments, and the symptoms

(including rehabilitation stage) or fever are will fade spontaneously.

postponed to get vaccinated. 2. Aseptic suppuration

3. If reaction of the whole body is

severe, the persons who get vaccinated

shall go to hospital for diagnosis and

treatment.

4. Diphtheria, tetanus and acellular

pertussis combined vaccine: the whole

body reaction or local reaction is very

slight.

Epidemic meningitis 1. Persons who have nervous system disease and After rejection, the reaction is alight, vaccine mental disease are forbidden to get vaccinated. and a few people have short-time fever,

2. Persons who have serious disease, such as kidney which often happens at 6 – 8 hours

disease, heart disease, active tuberculosis, etc. are after vaccination. Local is flush and the

forbidden to get vaccinated. pressure pain, and will gradually fade

3. Persons who have acute infectious disease and after vaccination

fever are forbidden to get vaccinated.

Epidemic Persons who have fever, acute infectious disease, After rejection, generally there is no encephalitis B otitis media, heart, kidney, liver disease, active reaction, and a very few persons will vaccine tuberculosis, allergic history or convulsions history have local flush, sometimes have fever,

are forbidden to get vaccinated; persons who have rash, allergic shock, angioedema, etc.

compromised immune system or are accepting

immunosuppressive therapy are forbidden to get

vaccinated.

Informed Consent Form for Vaccination Program Immune Vaccine (1)

1. HIB: hemophilus influenzae B conjugate vaccine 2. Hepatitis A vaccine

Preventable diseases: infectious diseases caused by

hemophilus influenzae B (meningitis, pneumonia, Preventable diseases: Hepatitis A septicemia, phlegmon, arthritis, epiglottitis, etc.)

1. Allergic people who are known to Hepatitis A inactivation Hepatitis A attenuation

be allergic with some content of the 1. People who are not feeling good vaccine, especially to tetanus toxoid, and the body temperature is over or allergic with inoculation of previous 37.5 ?. 1. Patients who have Hepatitis vaccine. and other serious diseases. 2. People who have acute infectious 2. The inoculation shall be delayed 2. Patients of febrile diseases shall disease or other serious diseases. Contraindication during active stage of fever or acute Contraindication delay the inoculation. 3. People who suffer from idiopathic diseases, especially infectious diseases 3. People who are known to be and acquired immune deficiency. or chronic diseases. allergy for any content of the 4. People who are receiving3. Normal reactions of immunization vaccine. immunosuppressive therapy. that can be reduced by 5. Pregnant women and people of immunosuppressive therapy and allergic constitution. immunodeficiency.

1. Partial reactions of injection

positions: pain, rubefaction or

inflammation. In general, this partial

reaction is early-stage, transient and

1. Partial side reactions are slight, and sometimes atypical rash

usually pain, and sometimes red can be observed.

& swollen, and indurate. 2. Extremely unusual cases may

2. Systematic side reactions appear edema of lower extremity,

Possible include headache, fever, nausea, No partial or systematic untoward along with cyanosis or transient

reactions after etc. The duration is usually less effect after inoculation of Hepatitis A purpura. This reaction usually appears

inoculation than 24 hours, and can relieve by attenuation inactivation vaccine. within the first few hours after

self. Possible inoculation, and usually quickly

3. The expectant treatment shall disappears spontaneously without any reactions after

be made in time for allergy sequela; there are usually no inoculation reaction. symptoms of disease and respiratory

system, and this occasion often

appears during simultaneous

inoculation with other vaccines.

3. Unusual allergy reaction cases may

appear in face or throat; rubella alike

rash, pruritus and edema.

4. Systematic symptoms: fever (usually Protective effect 95% lower than 39?), and enhanced

excitability and crying appear more

often.

Signature of visiting doctor: Date: Signature of visiting doctor: Date:

Signature of parent (s): Date: Signature of parent (s): Date:

Informed Consent Form for Vaccination Program Immune Vaccine (2)

3. MMR vaccine 4. Chicken pox attenuation and inactivation vaccine

Preventable diseases: measles, mumps, rubella. Preventable diseases: water mark – herpes zoster.

Domestic Imported

1. People who have

serious diseases and 1. Same with other vaccine, people who have

fever shall delay the acute serious fever diseases shall delay the People who have serious diseases, inoculation. inoculation, however, for healthy people, slight acute and chronic infection, fever or 2. People who have infection is not immune contraindication. allergic history with eggs shall not allergy history and 2. People whose total lymphocyte is less than inoculate. Contraindication pregnant women shall 1200 / mm3 or proved to lack cellular immune Pregnant women are forbidden to Contraindication be forbidden to use. function shall be forbidden to use. use, fertile women who inoculate 3. Patients of leukemia, 3. People who are known as hypersensitive with shall avoid pregnancy within 3 months tumor, neomycin shall be forbidden to use, but people after inoculation. immunodeficiency, etc. who have contact dermatitis with neomycin are

shall use with caution not included in the contraindication.

under doctor’s 4. Forbidden to use in pregnancy duration.

guidance.

1. Usually no side 1. Healthy people: comprehensive reactogenicity

1. Within 6 to 11 days, few children reaction after injection, of all the age groups are quite low, and the

may appear transient fever reaction or occasionally with slight reactions of injection position are usually slight

slight rash which will automatically partial reaction. and temporary.

Possible relieve less than 2 days. Possible 2. Rarely seen slight or 2. High risk patients: the reactions of injection reactions after 2. Adult women occasionally appear reactions after medium fever, position are usually slight; Papule

inoculation slight arthralgia, and need no special inoculation transient eruption for vesiculobullous rash may appear within several

treatment normally. Expectant less than 3 days. days or weeks after immune treatment, rarely

treatment can be made when Expectant treatment with slight to medium fever, and only less than

necessary. can be made when 1/4 leukemia patients have these reactions.

necessary. These rashes are usually slight and short.

Measles 99% Rubella 99% Mumps Protective effect Protective effect 99% 85%

Children’s Planned Immunization Program Immunization Appointment

Birth Date: March 15, 2005

Vaccines Date of Date of Meningo-AppointmenVaccine AppointmenVaccine AGE BCG HBV OPV DPT MV Encephalitis coccus A t t Vaccine

BaseMarch 31, 0month Base HBIG ? 2015

Morning, BaseNovember 1month influenza ? 13, 2007 vaccine

2month Base? 3 years

influenza 3month Base? Base? vaccine

4month Base? Base? Tuesday 5month Base? Morning

Base6month ?

7month

Base Second 8month 9month

1year 1.5years BooBooster Booster ster 2years Booster Booster 4years Booster Booster Please check if your child has completed the Booster Booimmunization as scheduled 6years Booster Booster DT ster

Immunization Appointment Immunization Record (I)

Lot Date of Date of Date of Number Unit of Vaccine Vaccine Vaccines Signature Appointment Appointment Immunization of Immunization

Vaccine

March 15, 2004060 Primaryimm 202+ 2005 47-1

BCG PPD July 21, 2005 12×12

202+

March 15, 2004080First Lina Zhao 2005 2 HBIG

Second 202+

Heping District March 15, 2004064 Tuberculosis Control 2005 9

HBV Base April 15, 2005 Gao

September 15, 2005902Yuan 2005 -2 Gao

May 17, 2005

Base June 27, 2005 Gao

September 28, OPV Yuan 2005

2010090 July 14, 2011 District Center Yuan 6 Booster

Please check if your child has completed the immunization as scheduled

Immunization Record (II) Immunization Record (III)

Vaccines Date of Lot Number of Unit of Signature Vaccines Date of Lot Number Unit of Signature

Immunization Vaccine Immunization Immunizatioof Vaccine Immunization

n

DPT Base June 27, 2005 Gao Meningococc1 March 16, 200506

us 2006 1402

A Vaccine July 28, 2005 Yuan 2 June 29, 200506

2006 2903

August 30, 2005 Yuan 3 July 27, 2010 090910

Booster October 8, 2006 Yuan 4 July 30, 2013 DP Booster August 18, 2011 YC37B045AA Gao Rubella

Vaccine

MV Base November 25, Yuan MMR August 1,

2005 2006

Booster August 1

MM Encephalitis B Base April 18, 2006 200411 Yuan MR Vaccine 2501

April 27, 2006 200411 Chen Varicella June 14,

2501 Vaccine 2006

Booster May 24, 2007 06110301 Yuan

June 16, 2011 20110106-1 District Center Gao Pneumococc

al Vaccine

Immunization Record (IV) Immunization Record (V)

Vaccines Date of Lot Unit of Signature Vaccines Date of Lot Unit of Signature

Immunization Number Immunization ImmunizaNumber Immuniza

Of tion Of tion

Vaccines Vaccines HIB 1 Influenza Novembe070729 District Yuan

Vaccine r 20, 2007 Center

2

3

4 HAV Attenuation 1 August

27

2

Deactivation 1 May 12, 09141303 Yuan

2011

2 April 19, 20122016 District Gao

2012 Center

Influenza Vaccines

Record Abnormal Reaction Instructions for Post BCG Vaccination

Unit and Conditio1. When BCG has been vaccinated for one month, there will be a blister Unit of Date of Vaccines Lot number n of at the vaccination position, and the pus will flow out. The blister will Immunization Reaction of Product Reaction gradually scab, and this is the normal reaction.

2. The blister shall not be squeezed, pay attention to keep dry and clean, 3. Individual newborn: after vaccinating for about a month, there may be

small lumps at left axilla or left clavicle; if the vaccination position still

has pus to flow out after three months, please contact various tuberculosis

controls.

Telephones of the Tuberculosis Controls in each County (City)

Heping: 23262448 Dongling: 24821443 Xinmin: 87853562 Record of Infectious Disease

Shenhe: 24844095 Yuhong: 25306689 Liaozhong: 87805638 Date of Disease

Dadong: 24312094 Sujiatun: 89814846 Faku: 87122890 Infectious Diseases Clinic

Huanggu: 86243204 Xinchengzi: 89862700 Kangping: 87347727

Tiexi: 25855402 Hunnan: 23821814

Telephones of Disease Prevention and Control Centers in Various District

(County)

Heping 23508243 Dongling: 24825287 Faku: 87123543

Shenhe: 31001561 Sujiatun: 89813277 Hunnan: 23825090

Dadong: 24312358 Yuhong: 25308304 Qipanshan: 88050032

Huanggu: 86230946 Xinmin: 62278778 Huishan: 88043445

Tiexi: 62382325 Liaozhong: 87882961 Huishan: 88043445

Xinchengzi: Kangping: 87335887 Remarks 89862118

Mother: HBsAg (+,–) HBeAg (+,–)

范文三：预防接种证查验

附表1: 入托、入学新生接种证查验和免疫状况登记表

______市_____县(市、区)______乡(镇)_____________幼儿园/学校_____班级 招生年份 200__年

儿童入托、入学时接种证查验、免疫状况登记

卡麻白麻年是是 介风甲肝减破疹 乙脑疫A群流脑疫A+C群流脑公历出生 级否否苗 乙肝疫苗 脊灰疫苗 百白破疫苗 腮毒活疫姓名 是否合是否补疫疫苗 苗 疫苗 年、月、日 班有补备注 初疫苗 格 种合格 苗 苗 级 证 证 种 苗

1 1 2 3 1 2 3 4 1 2 3 4 1 1 1 1 2 1 2 1 2 1

说明:1。此表用于学校儿童入托入学或转学时填～复印后报接种单位～本单位留存原件。托幼机构和学校及时根据接种单位反馈的补证和接种信息将儿童相应信息填入此表。

2.是否有证:是指入托入学或转学报到查验时是否有接种证。是填“?”～否填“×”,是否补证:是指入托入学或转学时无证～补证后填“?”～未补证时为空, 3.免疫状况登记结果:入托入学或转学报到验证时有接种记录～在相应疫苗剂次空格内填“?”,补种后～在相应疫苗剂次空格内填 “?”未补种时为空, 4.是否合格:是指入托入学或转学报到验证时是否完成全部免疫规划疫苗的全程接种～是填“?”～否填“×”,

5.是否补种合格:是指入托入学或转学报到验证时未接种疫苗或剂次不全者～补种所有未种疫苗剂次后填“?”～未补种全时为空,

查验人 责任人 查验日期 上报日期 单位,印章,

附表2:

已完成相关针次或疫苗补种儿童名单登记表

疫苗补种情况 备注

甲 卡麻肝白麻 介风A群A+C群减姓名 出生日期 年级班级 补证日期 破疹 乙脑疫苗 乙肝疫苗 脊灰疫苗 百白破疫苗 腮流脑流脑疫毒疫疫苗 初疫疫苗 苗 活苗 苗 种 苗 疫 苗

1 1 2 3 1 2 3 4 1 2 3 4 1 1 1 1 2 1 2 1 2 1

说明:1. 该表由接种单位根据“入托、入学新生接种证查验和免疫状况登记表” 填写所有入托、入学需补证、补种儿童的信息, 2. 儿童补证、补种剂次应填在相应栏目中,

3. 通知补证、补种而本次未补证补种的儿童应在备注中注明。

4、此表复印后反馈托幼机构、学校～原表留存接种单位。接种单位将儿童接种信息按要求填入接种证和接种卡薄。

填表人 填表日期 填表单位,印章,

附表3:

预防接种证查验、补种情况汇总表 ,省、市、县、乡及托幼机构,学校,汇总、上报使用,

_ ___省____ __市____ __县(市、区) 乡,镇, 托幼机构,学校, _ 接种单位

A+C群甲肝百白麻风卡介乙肝脊灰白破麻疹乙脑疫A群流脑流脑疫减毒破疫腮疫托幼机构,学查验人苗 疫苗 疫苗 疫苗 疫苗 苗 疫苗 苗 活疫苗 苗 校, 员培训 新苗 入实无实托补证应补托已入验证疾市县,补种幼开学证 ,应实应实应实应实应实应实应实应实应实应实应实控或乡卡种合机展或人卡补补补 补 补 补 补 补 补 补 补 补 补 补 补 补 补 补 补 补 补 补 机应已,镇, , 人格构查转数 ,种种种种种种种种种种种种种种种种种种种种种种构培培人数 人,验学人人人人 人 人 人 人 人 人 人 人 人 人 人 人 人 人 人 人 人 人 人 现训训数 数 学的人人人数 次次次次次次次次次次次次次次次次次次次次次次场校单数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 数 督,位导总数数 数 量

说明:1.无证人数:指新入托入学或转学报到验证时没有接种证的人数,实补证人数:是指已补办接种证的人数,

2.应补种人数:指新入托入学或转学报到查验时未完成免疫剂次的人数,

3.实补种合格人数:指需补种人数中～已补种所有未种剂次的人数,

4.应补种人次数:是指新入托入学或转学报到验证时应补种该疫苗人次数。如1 人2剂麻疹疫苗未种～则人次数为2。

5.实补种人次数:是应补种人次数中已补种该疫苗的人次数。

6.如托幼机构,学校,汇总上报～则不填写表中的第2、3列内容。

填表人 报表日期 填表单位,印章,

入托入学查验接种证和相关疫苗补种原则

根据江苏省新的扩大儿童免疫规划有关规定～各级要按照新的免疫程序～确保相关疫苗、相关年龄和针次数免费接种工作的落实。

1、甲肝疫苗:只需接种1针次冻干甲肝减毒活疫苗～以后不需加强免疫。对2006年11月1日以前出生的儿童不再享受免费接种～如确需补种的～要本着“群众自愿、费用自付”的原则进行接种。

2、麻腮风三联疫苗:2006年11月1日以后出生的儿童～只免费接种1针次初免,1.5岁,麻腮风三联疫苗。2006年11月1日以前出生的儿童～不再免费享受任何针次的麻腮风三联疫苗接种。

由于麻疹和腮腺炎发病率高～学校突发公共卫生事件中以腮腺炎暴发为主～所以建议对5，6岁儿童推广使用麻腮风三联疫苗加强免疫～但属于二类疫苗收费接种。因此～如需对2006年11月1日以前出生的儿童补种或对5，6岁的儿童加强免疫的～要本着“群众自愿、费用自付”的原则进行接种。

3、精制乙脑减毒活疫苗:每个适龄儿童仅在8月龄和2周岁免费各接种1个针次。

4、A+C流脑多糖疫苗:每个适龄儿童仅在3周岁和6周岁免费各接种1个针次。如果小学入学前已接种过两次A+C流脑多糖疫苗的儿童～则无需再行补种。

5、百白破三联疫苗:免费接种4个针次。

6、白破二联疫苗:免费接种1个针次。

7、麻疹疫苗:免费接种1个针次。

8、脊灰疫苗:免费接种4个剂次。

9、卡介苗:补种仅限3岁以下的初种漏种的入托幼儿。对小学入学新生不再实施查漏补种。在对3岁以下初种漏种的入托幼儿进行补种前～须

先进行PPD皮试～ PPD皮试阴性者方可补种～阳性者则不需补种。

10、乙肝疫苗:免费接种3个针次。

11、一、二类疫苗不得在同一天接种同一儿童。所有的一类疫苗与二类疫苗中的灭活疫苗,包括类毒素、多糖蛋白类等,的接种间隔至少在2周以上～一类疫苗中的减毒活疫苗与二类疫苗中的减毒活疫苗的接种间隔至少在28天以上。

上述规定自通知之日起实行。如有变动～另行通知。

范文四：预防接种证-英文

Notes: The charge vaccines uniformly distributed by Shenyang Center for Disease Control and Prevention are pasted with uniform mark, persons who are vaccinated should pay attention to check.

The injection cost is RMB 2.0 (LJF (2003) No. 35), and RMB 0.9 will be collected for self-destruction syringe if needed.

1. HIB: hemophilus influenzae B conjugate vaccine 2. Hepatitis A vaccine

Signature of visiting doctor: Date: Signature of visiting doctor: Date: Signature of parent (s): Date: Signature of parent (s): Date:

3. MMR vaccine 4. Chicken pox attenuation and inactivation vaccine

Children ’ s Planned Immunization Program Immunization Appointment

Birth Date: March 15, 2005

Please check if your child has completed the immunization as scheduled

Immunization Appointment Immunization Record (I)

Please check if your child has completed the immunization as

scheduled

Immunization Record (II) Immunization Record (III)

Immunization Record (IV) Immunization Record (V)

Mother: – ) – )

范文五：预防接种证制度

预防接种证制度 国家对儿童实行预防接种证制度。

在儿童出生后1个月内，其监护人应当到儿童居住地承担预防接种工作的接种单位为其办理预防接种证。接种单位对儿童实施接种时，应当查验预防接种证，并作好记录。 预防接种证制度内容 儿童离开原居住地期间，由现居住地承担预防接种工作的接种单位负责对其实施接种。 预防接种证的格式由省、自治区、直辖市人民政府卫生主管部门制定。

儿童入托、入学时，托幼机构、学校应当查验预防接种证，发现未依照国家免疫规划受种的儿童，应当向所在地的县级疾病预防控制机构或者儿童居住地承担预防接种工作的接种单位报告，并配合疾病预防控制机构或者接种单位督促其监护人在儿童入托、入学后及时到接种单位补种。

免疫预防接种证 预防接种证是儿童预防接种的记录凭证，每个儿童都应当按照国家规定建证并接受预防接种。儿童家长或者监护人应当及时向医疗保健机构申请办理预防接种证，托幼机构、学校在办理入托、入学手续时应当查验预防接种证，未按规定接种的儿童应当及时安排补种。儿童家长或监护人要妥善保管好接种证并按规定的免疫程序、时间到指定的接种点接受疫苗接种。如儿童未完成规定的预防接种，因故迁移、外出、寄居外地，可凭接种证在迁移后的新居或寄居所在地预防接种门诊(点)继续完成规定的疫苗接种。当儿童的基础免疫与加强免疫全部完成后，家长应妥善保管好接种证，它是儿童身体健康的身份证，以备孩子入托、入学、入伍或将来出入境的查验。”

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