Recommendations for Completing the International Certificate of Vaccination or Prophylaxis for Poliovirus Vaccination
The International Certificate of Vaccination or Prophylaxis (ICVP) is the official documentation used as proof of vaccination against a disease when a country entry requirement exists, as designated under the International Health Regulations (IHR). The Public Health Agency of Canada recommends issuing an ICVP to anyone receiving a vaccine or prophylaxis designated under the IHR, even if it is not administered to meet a country entry requirement. The Agency also recommends that the vaccination be documented in the traveller's personal immunization record.
The Public Health Agency has developed the following guidelines for completing the ICVP in relation to the World Health Organization's temporary recommendations to reduce the spread of poliovirus. Please refer to the example of a completed copy of the ICVP. The numbered recommendations below correspond to the numbers on the example document.
If a traveller has an existing valid ICVP noting previous yellow fever vaccination, the same ICVP can be used to record additional vaccinations for which the disease is designated under the IHR. There is no requirement for separate ICVPs for yellow fever and other vaccinations or prophylaxis designated under the IHR.
(1) Issued to
Print the name of the vaccinated traveller.
Yellow Fever Vaccination Centres
For Health Care Sites
(2) This is to certify that [name]
Print the name of the vaccinated traveller. All travellers, including children, must travel with their own individual certificate.
(3) Date of birth
Print the date of birth. The date format is day, month, year, with the month printed (e.g., 01 January 1975).
Print the sex of the vaccinated traveller. This should be recorded with the appropriate letter "M" or "F".
Print the nationality of the vaccinated traveller (e.g., "Canadian"). This should be the same as the nationality on the national identification document (e.g., passport) used by the traveller. If the traveller has more than one nationality, advise the traveller that completion of this line should be consistent with the national identification document with which he or she is travelling to avoid potential problems at border crossings.
(6) National identification document, if applicable
Enter the type of the traveller's national identification document (e.g., "Passport"). If there is any possibility that the traveller may travel with different types of national identification documents, completion of this line should reflect what has been previously entered on the nationality line. It is not advisable to enter the national identification document number, because this may expire prior to the end of the validity period of the certificate. This may lead to problems for the traveller at border crossings, as border officials may question why the traveller's current identification document number does not match the one listed on the certificate.
(7) Whose signature follows
Instruct the vaccinated traveller to sign the certificate. A parent or guardian should sign the certificate if the child is unable to write. An illiterate person should sign the certificate with his/her usual mark in the presence of the health care provider who should initial beside the mark.
(8) Has on the date indicated been vaccinated or received prophylaxis against: (name of the disease or condition)
Print "Polio" (or "Poliomyelitis"). If using an existing valid ICVP with "Yellow Fever" recorded, simply add "Polio" (or "Poliomyelitis") on the same line.
(9) Vaccine or Prophylaxis
Print the name of the vaccine that the traveller has received. Print "Polio" (or "Poliomyelitis") even if the vaccine was given in combination (e.g. Td-IPV or Tdap-IPV).
Print the date on which the traveller received the polio vaccine. The date format is day, month, year, with the month printed (e.g. 01 July 2014).
(11) Signature and professional status of supervising clinician
Sign the certificate and indicate your professional status. The signature should be that of the health care provider administering the polio vaccine. If this is not possible (i.e., transcribing the record of a previous polio dose given within the 12 month period by another vaccine provider); clearly record the name and designation of the person who administered the vaccine and the name of the transcriber, e.g., administered by "...", transcribed by "...".
(12) Manufacturer and batch no. of vaccine or prophylaxis
Print the name of the pharmaceutical company and the batch number of the vaccine.
(13) Certificate valid from: until:
Print the dates of the validity period of the certificate. The certificate is valid starting on the date of vaccination and expires 12 months (one year) from the start date of validity. The date format is day, month, year, with the month printed for both start and end date.
(14) Official stamp of administering centre
Stamp the certificate with the unique identification stamp of the designated Yellow Fever Vaccination Centre. This stamp can be used as a temporary measure to validate administration of the polio vaccination.
Example of a Completed Copy of the International Certificate of Vaccination or Prophylaxis for Poliovirus Vaccination
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