AERRERRRER ER Health Certificate for Residence Application CRRA A shat + Sis + EK) (Hospital's Name, Address, Tel, Fax) SRS Hospital’s Logo eH aM / Date of Examination & AF A / Basic Data HZ, ea ee sx (U2 /M OX/F SPEER HRRA IDNo. Passport No. WET ata aa LH / Photo Date of Birth Nationality” a RSEe Age Phone No. & & = # & / Laboratory Examinations ‘A. Mat XAFS / Chest X-ray for Tuberculosis ¢ X AER [Findings HR [Result : Cl 4a (Passed (] Rw ss# ITB suspect C] AREY; [Pending O RSS / Failed (CD 4% 12 RAF LE RAK / Not required for pregnant women or children under 12 years of age B. aS FSR ARBH / Stool Examination for Parasites : Cl PHIL» #% / Positive, Species (1 Bet / Negative CD RWTAFRLHN SA A / Other parasites that do not require treatment CO AAMAS 2 BREA RA / Not required for applicants from countries/areas listed in Appendix 3 C. Hi FALH / Serological Tests for Syphilis + Hei Tests a ORPR Cl VDRL OBE [Positive » 24% /Titers CO PIE / Negative > zt / Titers >.) TPHA [)TPPA C] FTAsbs (] TPLA [1] EIA -(] CIA BH [Positive » 248 / Titers Co BME / Negative » 25 / Titers ce. O other CBRE / Positive » 4% / Titers Cl BE / Negative + 344 Titers FIR (Result: ] SH [Passed () R44 / Failed (7 15 RAAF 2B KAR /Not required for children under 15 years of age D. HHABARSLABMERSARS LAG BAEE / Proof of Positive Measles and Rubella Antibody or Measles and Rubella Vaccination Certificates ¢ 2, HaLARE / Antibody Tests BIHAR /Moases Antibody C] He /Postive CMH /Nesatve C) ASR /Equivocel 4B RVG / Rubella Antibody 1] Ryte / Positive [] BAe / Negative [] AA / Equivocal b. HiwRAEA / Vaccination Certificates (ARCHES BART AR ERR | HEM Sh Bl BRE) MRR IM / The certificate should include the date of vaccination, the name of ‘administering hospital or clinie and the batch no. of vaccine; the date of vaccination should be at least two ‘weeks prior to traveling overseas.) | 0 RRR eR ABBEMA / Measles Vaccination Certificate | D @mmsqereeaxe% / Rubella Vaccination Certificate sc. D1 F#M#S » YAW TAAL / Having contraindications, not suitable for vaccination% 4% Ss Ae H / Examinations for Hansen’s Disease 2SRRRBER | Skin Examination 0 £@ /Normal C1 8% /Abnormal : Q 3b 43% / Notrelated to Hansen’s disease © O RURAL SAE—FAE /Hensen’s disease suspect who needs further examinations a, MAF | Skin Biopsy : b. ARKH /Skin Smear: © Miz /Positive O te / Negative ©. BLA ALA SE A SP ABAE A / Skin lesions combined with sensory Joss or enlargement of peripheral nerves : Q # /Yes © i /No ALR / Result: OC #% /Passed 1] M&—HARH / Needs further examinations [] #E# / Failed O RA Heke B R/2 GH HM / Not required for applicants from countries/areas listed in Appendix 4 ‘XBR / The final result of health examination : O #8 /Passed (] Ai&8—-H4RB | Need further examinations [1] A446 / Failed AF BRHRE / Signature of Chief Medical Technologist : AK BHBE / Signature of Chief Physician : BRA AARE / Signature of Superintendent : age /Date: ‘iE / Note! AES 4G A PA AL + / The certificate is valid for three months.