Immunisation Registration Form Hoath

Board
SECTIONI: Personal Information
Name of Applicant :SMRITH) KARTH1K Travel Document No. : B9213619
Date of Birth :23/o2023
Gender : o Male female
Country of Birth
:LNDIA
SECTIONIl :Immunisation Information
up this registration form.
Please read the Useful Information carefully before filling
A) Compulsory Vaccinations
Dose Date oflmmunisation Vaccine Name Exempted Singapore Immunisation Requirements (Application Approval Criteria)
S/N (DD/MM/YYYY)
Sequence Minimum age for Diphtheria vaccination is 6 weeks old
1 |Diphtheria, Tetanus, Pertussis
Minimum interval to next vaccine dose
DD/MV/YYY
|Dose 1 1/2/3): 4 weeks
- between each Primary dose (i.e. Dose
Dose 2 (i.e. Dose 3 and Booster 1):
- between Primary dose and Booster dose
Dose 3 DOMY
6 months
Booster 1
DD/MMYYYY between Booster dose (i.e. Booster 1/2) :6 months
Booster 2 months old
Minimum age for Measles vaccination is 12
2 Measles
*No. of Measles vaccination to be completed:
|Dose 1 DD/M/YYYY
-1 dose if child is 12 months and above
Dose 2
-2 doses if child is 15 months and above
Minimum interval to next vaccine dose:4 weeks

B) Recommended Vaccinations
Date of lmmunisation Singapore Immunisation Reguirements
Dose Vaccine Name
s/N Sequence (DD/MM/YYYY)
3 Tuberculosis

Dose 1 A5lo 83 ToRERVAC * Minimum interval to next vaccine dose:

4 Hepatitis B
between Dose 1 and Dose 2:4 weeks
Dose 1

Dose 2
aFtola3 GENEVAE
8lialo_GENEVAC B
between Dose 2 and Dose 3:8 weeks

Dose 3 81pl GENEVAC B * Minimum age for Polio vaccination is 6 weeks old
Polio OPV Minimum interval to next vaccine dose:
Dose 1 DD/MMrY
DO/MMYYYY between each Primary dose (i.e. Dose 1/2/3) :4 weeks
Dose 2 Booster 1): 6 months
between Primary dose and Booster dose (i.e. Dose 3 and
Dose 3
- between Booster dose li.e. Booster 1/2): 6 months
DOIMMAYY
Booster 1
Booster 2 DD/MM/YYYY

SECTION II: Declaration

For Certifying Doctor
For Parents/ Guardian of applicants entered by me on
Ihereby declare that, to the best of my knowledge, all information
this Form is true and correct,
Ihereby declare that all information provided by me on this Form is true and correct, and that I have
obtained documentarv proof of the
thatI have provided documentary proof of the vaccination(s) to the Certifying vaccination(s) that was administered elsewhere. I understand that giving false or
and
elsewhere. I understand that giving false
Doctor if the vaccination(s) was administered misleading information to any public servant of the Singapore Health
Promotion Board
of the Singapore Health Promotion
or misleading information to any public servant ("HPB") and the National Immunisation Registry could amount to
a serious offence.
could amount toa serious
Board ("HPB")and the National Immunisation Registry which may result in legal prosecution.
offence, which may result in legal prosecution. Doctor to maintain proper
Iunderstand that it is my responsibility as the Certifying
in this Form will be submitted online via
Iunderstand that all information provided records of the photocopies and/or softcopies of this duly completed Form and
any
HPB's Terms of Use (link:
HPB's website(s) and therefore subject to documentary proof of the Applicant's vaccination(s) therein, which may be
required by
https://www.hpb.gov.sg/terms-of-use), and Privacy Statement (link:
HPB for auditing and/or examination purposes in the future.
https://www.hpb.gov.sg/privacy-statement) as stated on its websites, which I have
read and understood.
to
as the Parent/Guardian of the Applicant
Iunderstand that it is my responsibility any
copies of this duly completed Form and
maintain proper records of the original Name/Signature & Date
therein, which may be required by
documentary proof of the Applicant's vaccination(s)
purposes in the future.
HPB for auditing and/or examina
o eSQRemANAM) Name in Local Language (Please indicate clearly) (L nnnNm
Practice Licence No. :
Name/Signature & Date:

Relationship: DFather hother o Guardian Clinic/Hospital Name &Stamp:D Hei AasAtast Pedatcae &Neonafologist
0275
Email & Contact Phone No.

Address2-Arto loay
Vaoccination Requirements (for Entry to Singapore)"
1 "Name of Applicont" refers to the nome of child who is apphying for the "Verification of
Voccination Requirements (for entry to Singapore)" to Heath Promotion Board (HPB) and long-Berm immlgration pass
"Travel Document No." refers to the document which the applicant will use for the opplicotion of "Verification of
to
TheMinistry of Manpower
travel document (e.a. (MOM),
Passport) should havePass(DP)
Dependant's LongofTerm
o validityordate
Visit Pass (LTVP) or Immigration & Checkpoints Authority of Singopore (CAJ, Student's Pass (STP).
at least six months at time of application to HPB. The some trovel document should be used for application at both HPB and MOM or ICA.
3 "Compulsory Voccinations" refers to voccinations which ore cormpukory under Singopore Infectious Diseases Act. Informotion on Singapore Infectious Disease Act is available at https://www.moh.gov.sg/policies-and
legislationinfectious-diseaseact
4 Vocine Nome" refers to avoccine code or trade name of the vaccine. Examples of vaccine code and vaccine name can be found in Appendix A.
5 "Exempted" refers to the opplicont being exempted due to medical reason. Acopy of exemotion document cetiied by a doctor is required. All exemption cases will be subjected for review and opproval by HPB. There will be no
efund ofapplication fee if reoson of exemption is rejected by HPB.
6 Any dose of measles-containing vaccine given before 12 months of oge should not be counted as part of the series. Children vaccinated with measles containing vaccine before 12 months of oge should be re-voccinated with two
doses of MMR voccine, the first of which should be administered when the child turns at least 12 months of oge. [Reference to Centers for Disease Control and Prevention publication 'Epidemiology And Prevention of Vaccine
Preventable Diseases 13th Edition).
7 "Recommernded Voccinations" refers to voccinotions lsted in the Singopore National Chldhood immunsiation Schedule (NCIS). infomation on Singapore National Childhood Immunsiation e-Schedule (NCIS] is available ot
https://www.nir.hpb.gov.sg/nirp/eservicesfimmunisationSchedule
8 HepA
Combination voccines containing ahepotitis Bcomponent (e.g, nfonrix hexa, Pentovac PES) ore avoilable. These voccines should not be administered to infonts younger than 6weeks because of the other components (e. Hib, DTaP,
and IPV).

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Roard

B) Recommended Vaccinations
Dose Date of lImmunisation Vaccine Name
S/N Singapore Immunisation Requirements
Sequence (DD/MM/YY)
6 Haemophilus Influenzae Type Minimum age for Hib vaccination is 6 weeks old

Dose 1 DD/MMYYYY Minimum interval to next vaccine dose:

Dose 2 DD/MM/YYYY -between each Primary dose (i.e. Dose 1/2/3) : 4 weeks
Dose 3 DD/MM/YYYY - between Primary dose and Booster dose (i.e. Dose 3 and Booster 1): 6 months
Booster 1 DDMMYy
Pneumococcal Minimum interval to next vaccine dose:
Dose 1
81aj83PREVANAR -between each Primary dose (i.e. Dose 1/2): 4 weeks
Dose 2
Booster 1
alotlaPeEVAJAe between Primary dose and Booster dose (i.e Dose 2 and Booster 1): 8 weeks

Human Papillomavirus Recommended for females 9 to 26 years

Dose 1 oD/MMYY Minimum interval to next vaccine dose:
Dose 2 DO/MM/YY -2 dose series at 0, 6 months
Varicella (Chicken Pox) Minimum age for Varicella vaccination is 12 months old
Dose 1 DO/MM/YY Minimum interval to next vaccine dose :

Dose 2 DD/MM/YYYY -between Dose 1andDose 2:3 months

10 Influenza Minimum age for Influenza vaccination is 6 months old
Dose 1 DD/MMIYYYY Minimum interval to next vaccine dose:
Dose 2 DD/MMYYY Age 6 months to 8 years:
DD/MM/YY - 2dose series 4 weeks for children receiving Influenza vaccination for the first time
Dose 3
Booster1 DD/MM/YYY -1 dose for all other children annually or per season or as recommended
" Pleose only input the latest 4 doses during online Age 9-12 years:
application -1 dose annually or per season or as recommended
" Please fill up Table 1 for any additional dose(s) taken.

Table 1:Optional Vaccination

Date (DD/MM/YYYY) / Vaccine Name
s/N Immunisation* Dose 4 Dose 5
Dose 1 Dose 2 Dose 3

5
6

* Please refer to AppendixA for Vaccine Code and Vaccine Name

National Childhood Immunisation Schedule (NCIS)

(from birth to age 17 years, effective from 1November 2020)
12 15 2-4 5-9 10-11 12-13 13-14 15-17
Vaccine Birth
months Months months months months months years years years years years years

BacilusCalmette-Guerin(BCG)
02 D3
Hepatitis B(HepB)
Diphtherla, tetanus and acellular D3
pertussh (paediatrtc) (DTaP)
B2
Tetanus, reduced iphtheria and
acellular pertusss (Tdap)
D2 D3 B2
Inacthyated pollovirus (1PVM)
D3 B1
Hoemophlus influenzoe type b D1 D2
(HIb)
D D B1
Pneumococcal conjugate
(PCV10 or PCV13)
One or hwo doses for chlidren and adolesents age 2-17 years with specifk
PneunotOLal polysaccharide
medkaf condtlon or indication,
(PPSV2)
D2
Measle, mumps and rubella
(MMR)
Varkela (VAR) D2

Hu men Paptlomavrs
(Females) (Females)
lnfluena(INEI Annual vaccination or per season tor plchild en age 6 months to Annual vectlnatien or per season lor chedren andadciescents
<S years (6-59 months). age S-17 years wth specitk medikal conditlon or kndkation,

Recommended ages and doses lor all children Recommended for persons with speciflc medkal condltlon or lndkatlon

FOOTNOTES:
D1, D2, D3: Dose 1, dose 2, dose 3
B1, 62: Booster 1, booster 2

Voccine Nome"refers to ovaccine code or trade name of the vaccne. Examples of voccine code and vaccine name con be found in Appendb A.
"Recommended Vaccinations" refers to voccinations listed in the Singogpore Nationgl Childhood Immunslation &Sehedule (NCLS). Information on Singgpore National Childhood immunsiation &- Schedule (NCIS) is ovailableot
htps://www.nirhpb.govsg/hiplesericesfimmunisationSchedule

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