![](data:image/png;base64,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)
年 日
date
1
年 月 日
1. Name of the inoculated person: ( ) Date of Birth:
3. Name of medical Instituion
現在妊娠している可能性(生理が予定より遅れているなど)はありますか。
メーカー名
ロット番号
1. 適 YES
2. 否 NO
Propriety of inoculation
Parent/Guardian's column and confirmation of agreement (in case recipient is over 13years old and without any person to accompany)
I have read the explanation on HPV vaccination and, understanding the effects, purpose, potential serious side effects of the vaccination and inoculation
heath relief system. Based on the above, I (Agree or Disagree) to the implementation of the Vaccine.
今日の予防接種について質問がありますか。
ある場合 ( )
6か月以内に輸血或いはガンマグロブリンの注射を受けましたか。
Do you have any questions about today's vaccination?
If yes, please describe. ( )
はい
Yes
西暦
A.D.
Code
いいえ
No
いいえ
No
実施医療機関名
Signature of parent/guardian or its representative or by the recipient herself if she is married.
Doctor's Name. In case of "no", name of the Doctor
who made the judgement
Code
医師 の記 入欄
保護者に対して、予防接種の効果、副反応および予防接種健康被害救済制度について、説明をしました。
Doctor's column
I made explanation on the effectiveness of the vaccination, side reactions, and the vaccination health hazard relief system.
Signature or seal of the Doctor in charge
(注)ガンマグロブリンは、血液製剤の一種で、A型肝炎などの感染症の予防目的や重症の感染症の治療目的などで注射されることがあり、この注射を3~6カ月以内に受けた方は、麻しんなどの予防接
0.5ml
HPV防接種
1回目・2回目・3回目]
Remark ; Granma Globulin is a blood product to be injected for prevention of infection diseases like Hepatitis A and for treatment of serious infection diseases. There are cases that vaccination of measles etc.,
may not e effective for those people who received Gamma Globulin injection in the past 3 to 6 months
医師署名又は記名押印
保護者(または代理者)の記入欄 (保護者(または代理者)が同伴する場合、または、接種を受ける人が既婚者の場合は本人)
(※代理者が記入する場合は、別途「委任状」が必要です)
医師の診察・説明を受け、予防接種の効果・目的、重篤な副反応の可能性、予防接種健康被害救済制度などについて理解したうえで、接種することに( 同意
します・ 同意しません)。 ※かっこの中のどちらかを○で囲んでください。「同意しません」は接種できません。
この予診票は、予防接種の安全性の確保を目的としています。このことを理解のうえ、本予診票が千葉市に提出されることに同意します。
HPV vaccination for record for recipient) [1st ・ 2nd ・ 3rd]
緊急の連絡
3.
)
disagree, vaccination will not be made. Understanding that this questionnaire is to
I (Agree or Disagree ) to the vaccination.
secure the safety of vaccination, I agree that it will be submitted to Chiba City.
This column is to be filled in by parent/guardian or by the representative or recipient herself if she is married.(in case of a representative, a seperate
power of attorney is required.)
Recipient received medical examination and I received the explanation by the doctor. I further received explanation about the effects, purpose, potential
serious side effects of the vaccination and vaccination heath relief system. Based on the above, I (Agree or Disagree) to the implementation of the
Vaccine. (※ Please circle either of Agree or Disagree in the parenthesis.) In case of disagree, vaccination will not be made. Understanding that this
questionnaire is to secure the safety of vaccination, I agree that it will be submitted to Chiba City.
Dosage
筋肉内接種
接種の適否 接種量 接種医師名(接種否の場合は判定医師)
Month
月
Name of Institution
保護者(または代理者)自著
※妊婦または妊娠している可能性のある方への接種は望ましくありません。
Is there a possibility that you might be pregnant, for example, delayed menstruation, etc. ?
※ This vaccine is not recommendable to a pregnant, or to those who might be pregnant.
はい
Yes
いいえ
No
はい
Has the child received a transfusion of blood or an Injection of gamma globulin in the past 6 months? Yes
(※ Please circle either of Agree or Disagree in the parenthesis.) In case of
1 被接種者氏名 (
生年月日 年 月 日
2 住所 千葉市 区
4 接種年月日
Year
メーカー名
Parent/guardian Signature
Address
Emergency contact
保護者の記入欄兼同意書 (接種を受ける人が13歳以上で保護者が同伴しない場合)
HPV予防接種を受けるにあたっての説明を読み、予防接種の効果・目的、重篤な副反応の可能性、予防接種健康被害救済制度などについて理解した
うえで、接種することに(同意します ・ 同意しません)。
保護者自署
住所
※かっこの中のどちらかを○で囲んでください。「同意しません」は接種でき
ません。この予診票は、予防接種の安全性の確保を目的としています。こ
のことを理解のうえ、本予診票が千葉市に提出されることに同意します。
Manufacturer
Lot No.
有効期限
Expiration date