Procedures for Yellow Fever Vaccination Centres in Canada
Example of a completed International Certificate of Vaccination or Prophylaxis
Front page:
Title: International Certificate of Vaccination or Prophylaxis
International Health Regulations (2005)
Issued to:
Josephine Doe (1)
On the inner pages, the health care provider must complete all fields appropriately. If the certificate is not completed properly, it may be considered invalid.
Inside pages:
International Certificate of Vaccination or Prophylaxis
This is to certify that (name):
Josephine Doe (2)
Date of birth:
12 March 1970 (3)
Sex
F(4)
Nationality:
Canadian (5)
National identification document,
if applicable:
Passport (6)
Whose signature follows:
Josephine Doe (7)
has on the date indicated been vaccinated or received prophylaxis against (name of disease or condition):
Yellow fever (8)
in accordance with the International Health Regulations
Vaccine or prophylaxis:
Yellow fever (9)
Date:
15 August 2016 (10)
Signature and professional status of supervising clinician:
John Smith R.N. (11)
Manufacturer and batch no. of vaccine or prophylaxis:
Sanofi Pasteur Lot # C035AA (12)
Certificate valid from:
25 August 2016
Until:
life of person vaccinated
Official stamp of the administering centre:
Official stamps are provided to Yellow Fever Vaccination Centres. There are three lines on the stamp:
Line 1, "YFVC/CVFJ";
Line 2 displays the identification number assigned to the Yellow Fever Vaccination Centre. The number contains the code of the province where the site is located, followed by a unique 4-digit number (e.g. XX-1000);
Line 3: "CANADA". (14)
Back page:
This certificate is valid only if the vaccine or prophylaxis used has been approved by the World Health Organization.
This certificate must be signed in the hand of the clinician, who shall be a medical practitioner or other authorized health worker, supervising the administration of the vaccine or prophylaxis. The certificate must also bear the official stamp of the administering centre; however, this shall not be an accepted substitute for the signature.
Any amendment of this certificate, or erasure, or failure to complete any part of it, may render it invalid.
The validity of this certificate shall extend until the date indicated for the particular vaccination or prophylaxis. The certificate shall be fully completed in English or in French. The certificate may also be completed in another language on the same document, in addition to either English or French.
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