BORLA RERERBR Health Certificate for Residence Application CHER EAH Hak > Eis» AK) deat 4 Date of Examination (Hospital's Name, Address, Tel, Fax) 2228 / OY) BI BRR Hospital’s Logo & A KH HF / Basic Data #4: Salata Nekete #9 Og Mm We/F STEER. AMAA, iehapieal Passport No, MU45834 5 ASA A |2UNE/ l/ 22 |Nyaomnty | Uapenese a, WHE at 14 belated onde R Me B te & / Laboratory Examinations ‘A. MSR X Jas BAA / Chest X-ray for Tuberculosis ? X AHR | Findings * rmal (2093 /03 (2 FIZ / Result? 1 S¥e (Passed (] eA AA /TB suspect [] kA; /Pending C] AH / Failed [) Bis 12 LCF LS HAE / Not required for pregnant women or children under 12 years of age B, BA FLARAMS / Stool Examination for Parasites : (CO Bt > & / Positive, Species —__ ____ [1] Bt / Negative (Sete 126 FR BHA Fe ae / Other parasites that do not require treatment [Hf RAMS=S2 A FAEEH KAM / Not required for applicants from countries/areas listed in Appendix 3 C. Hehe | Serological Tests for Syphilis * ‘eli | Tests © a. (4 RPR [] VDRL is (Co BRE (Positive » xtfit / Titers [Of BRA (Negative » at / Titers b. DU TPHA [) TPPA [J FTA-abs (4 TPLA [) EIA [1] CIA (1 Bb / Positive » 24% / Titers (Uf BRE / Negative > ak 4 / Titers ©. Cl other (] AK [Positive » kA / Titers () BHE / Negative » ae/ft / Titers HR [Result S4e /Passed [] FS / Failed (Cl 15 i sx-F & &MH / Not required for children under 15 years of age D. Ru Att BROS ZALES ARG Bb BALE / Proof of Positive Measles and Rubella Antibody or Measles and Rubella Vaccination Certificates ? a. dhe / Antibody Tests RBZ /Measles Antibody [1] BE /Positive (] AEE /Negative (] 4xstis@ /Equivocal {SBLRLILAR / Rubella Antibody (] Brit [Positive C] BRA /Negative [1] Asie / Equivocal APSHRAGMEH/ Vaccination Certificates (HEH NE OHA AM > RAPE AA WEE HAE A IT 9 1 8 YAM B/Y BRA / 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.) (mi HF RAGEEAA/ Measles Vaccination Certificate (U BLM HEF RAEN / Rubella Vaccination Certificate c. Cl HRMS > YW x HMA / Having contraindications, not suitable for vaccination =i 2% MH / Examinations for Hansen's Disease 2H AWA [Skin Examination CO £% /Normal CX (Abnormal : Q 43K /Not related to Hansen's discase + O Ri 2 RRR —P ese. /Hansen’s disease suspect who needs further examinations a, 38498 | Skin Biopsy : b. RMARK Skin Smear: OQ Mytt / Positive OQ Pit / Negative C. OO EAR SAPMAEA / Skin lesions combined with sensory loss or enlargement of peripheral nerves : © 4 /'¥es O #& /No ALK / Result: (] 44% (Passed C] RR—HHH (Needs further examinations [] 4-46 / Failed AR A Ni sihea & Wl %/H1G A SMe / Not required for applicants from countrcs/areas listed in Appendix 4 4@ Ae 1B45 R / The final result of health examination OU 4A /Passed () SR—SH Hes /Need further examinations ] 2K / Failed a SH Bile H / Signature of Chief Medical Technologist : S/W21 Lhamelo Awe / Signature of Chit Physician | Sic Chaat) A ABE / Signature of Superintendent : Yukio Shiu! at — BM / Date + 2828 / DA / 24) 3 / Note | AEH S18 A MAH > / The certificate is valid for three months. Health Care Center & Clinic Kwansei Gakuin University 1-155, Uegahara-Ichibancho Nishinomiya, Hyogo, Japan 662-1 ~8501 +81-798-54-6095