Description - International Certificate of Vaccination or Prophylaxis for Poliovirus Vaccination

This image is an example of a completed International Certificate of Vaccination or Prophylaxis, the official certificate which must be used to record vaccination against poliomyelitis (polio). The numbered examples correspond to each line that must be completed. Please refer to “Recommendations for the Completing the International Certificate of Vaccination or Prophylaxis (ICVP) for Poliovirus Vaccination” on the Agency's website for more information

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. 

INSIDES PAGES:

International Certificate of Vaccination or Prophylaxis

This is to certify that (name):

Date of birth: 

Sex

Nationality:

National identification document, if applicable:

Whose signature follows :

has on the date indicated been vaccinated or received prophylaxis against (name of disease or condition):

Vaccine or prophylaxis:

Date:

Signature and professional status of supervising clinician:

Manufacturer and batch no. of vaccine or prophylaxis:

Certificate valid from:
Until:

Official stamp of the administering centre:

Josephine Doe (2) 

12 March 1970 (3)

F(4)

Canadian (5)

Passport (6) 

Josephine Doe (7)

Polio (8)
in accordance with the International Health Regulations

Polio (9)

10 July 2014 (10)

John Smith R.N. (11)

Manufacturer name Lot # XXXXXX (12)

10 July 2014
09 July 2015 (13)

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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