Immunisation Registration Form

ECTIONI:Perongl ntomgtign
Name of Applicant SMRITHI kARTHIK Travel Document No. : B9213619
Date of Birth : 25 10 2023
Gender
:D Mae female CountrY of Birth
:TNDIA
SECTION t: Lmmynisation Information
up this registration form.
Please read the Useful Information carefully before filling
AJCompusory Vaccinations
Date of Immunisation Exempted Singapore Immunisation Requirements (Application Approval Criteria)
Dose Vaccine Name
S/N (DD/MM/n
Sequence Minimum age for Diphtheria vacination is 6 weeks old
1 Diphtheria, Tetanus, Pertussis
Minimum interval to next vacine dose:
Dose
08 21201|HEXAXIm R -between each Primary dose i.e. Dose 1/2/3): 4 weeks
Dose 2 ORlol2024|HE
DDMM/YY
XAXI1 R -between Primary dose and Booster dose (i.e. Dose 3 and Booster 1):
Dose 3
6 months
Booster1
-between Booster dose (i.e. Booster l/2):6 months
Booster 2
Minimum age for Measles vacdnation is 12 months old
2 Measles
No. of Measles vaccination to be completed:
Dose 1
-1dose if child is 12months and above
Dose 2 DOMM
)doses if child is 15 months and above

Minimum inteval to next vaccine dose:4 weeks

B)Recommended Vaccinations
Date of Immunisation Singapore Immunisation ReQuirements
Dose Vaccine Name'
S/N (DD/MMY)
Seguence
3 Tuberculosis
Dose 1
Minimum intenval to net vacone dose
Hepatitis B
-between Dose 1 and Dose 2: 4 weeks
Dose 1 1R5 lio/2023|R&VAC -B
HEXAXM-R-between Dose 2and Dose 3: 8 weeks
Dose 2 08/122023
Dose 3
Minimum age for Polio vaccination is 6 weeks old
Polio
Minimum intenval to net vaccine dose:
Dose 1
|ogI12l2023 HEXAwrg-R -between each Primary dose (i.e. Dose 1/2/3): 4 weeks
|Dose 08loil2024 HEXAXIN-R between Primary dose and Booster dose (i.e. Dose 3 and Booster 1):6 months
Dose 3
-between Booster dose (ie. Booster 1/2):6 months
Booster 1
Booster 2
SECTION : Declaration
For Certityng Doctor
For Parents/Guardian of applicants
Ihereby deciare that, to the best of ny knowledge, all informalion entered by me on
I hereby declare that all information pravided by me on this Form is true and correct
this Form is true and correct, and that I have obtained docunentary proof of the
Certifying
and thatIhave provided documentary proof of the vaccination(s) to the vacCinaton{s) that was adminstered elsehere. Iunderstand that giVIng false or
Doctor if the vaccination(s) was administered elsewhere. I understand that giving false misleading information to any pubic servant of the Singa pore Health Prormotion Board
or misleading information to anypublic servant of the Sngapore Health Promotion (HPB") and the National Immunisation Registry could amount to a seroUs offence,
Board ("HPB") and the National Immunisation Registry could amount toa senous
which may result in legal prosecutson
offence, which may result in iegal prosecution Iunderstand that t is my fesponsibity as the Certitying Doctor to maintaln proper
submitted online a
I understand that all information provided in this Form will be records of the photocopies and/or softcop.es of this duly completed Form and any
HPB's websitels) and therefore subject to HPB's Terms of Use (lunk:
https://www.hpbgov.sg/terms-of-use), and Prtvacy Statement (lnk: documentary proof of the Appiicant's vaccination(s) the fein, which may be required by
https://www.hpb.goV.sR/privacy-staterment) as stated on its websites, which I have HPB for suditng and/ot examinaton purposes in the future.
read and understood.
I understand that it is my responsibility as the Parent/Guardian of the Appicant to
Form and any
maintain proper records of the original copies of this duly completed
documentary proof of the Applicant's vaccinatson{s)therein, which may be requred by Name/Sgnature & Date
no3I72
Nane in iacal Lange(Penengene ceaty
HPB for auditing and/or examination purposes in the future.
(ANIANASUGRAMANAM)
Practice Licence No. :
Name/Signature & Date

Relationship : o Father hother o Guardian CinicMosptal Name &StampDe. HEtAosAitant Pedatrcne &Hecna<ologist
Ematl & Contact Phone No.
50275

Nome f Applcast" refers to the name of hid who s apohng for the verfcation of Vaxontion Requtements o Entry to Srgpore)"
"Irove Documert No refers to the document which the applcant wt use fo the appcation of Vefcaton of Voccneon Reouremerts (for ety to Sir gapoe' to Heah Promat.on Boord (HPB) ord lorg term mngyutin poas
to Minatry o Morpower (MOM Drpendant's PaasDP) or Long Term Var Pass (2TVP) or immgrat.on& Checkpants Autharty of Singapore (KCA) Suder's Pars (STP)
The trave dacuherd leg Passport) should hove a vadty date of a least str months at tne of applcation to HPR The some trovel document shaud be used fo oppicotion ot bth HPB and MOM or ICA
Tanpuory Vaccinat ons efets te occnatsons which are compukory under Singgpore intetos Deseoses Act Informaion on Snganore htetious Disease ktis Ovalable at httpsIhwww mch gov sg/poácies and
legaatngao dsease-ort
verne Nam' rters toe rcne code or trade name of the vatne. Exampis f vaccne code and warcne name can be found n Aperndu A
T o t en to the avplkat brng epmted due 1o medcoi rerason Acopy of earnpton drument cetfed byodotor a regured Al empton cases wd be subrted for ieewond apgrva by E Ihere wd be ey
schea tet e n a engtion in red by P

Pnetae raes r Edian

 Bosru

B) Recommended Vaccinations
Dose Date of lmmunisation Vaccine Name Singapore Immunisation Reguirements
S/N (DD/MM/YYYY)
Sequence Minimum age for Hib vaccination is 6 weeks old
6 Haemophilus Influenzae Type E
Minimum interval to next vaccine dose:
|Dose 1 O8/122023 HEXAXIM R. between each Primary dose (i.e. Dose 1/2/3) :4 weeks
Dose 2 |O8lol2024 HExAXIM R - between Primary dose and Booster dose (i.e. Dose 3 and Booster 1): 6 months
Dose 3
Booster 1
Minimum interval to next vaccine dose :
Pneumococcal
-between each Primary dose (i.e. Dose 1/2) : 4 weeks
Dose 1 03l22o23|PREVANARI between Primary dose and Booster dose (i.e Dose 2 and Booster 1):8 weeks
Dose 2 08/o20214PREVANAR-I
Booster 1
Recommended for females 9 to 26 years
Human Papillomavirus
Minimum interval to next vaccine dose:
Dose 1 DD/MMAn
-2dose series at 0, 6 months
Dose 2
Minimum age for Varicella vaccination is 12 months old
Varicella (Chicken Pox)
Dose 1 O/MM/YrY Minimum interval to next vaccine dose
DD/MM/YYYY between Dose 1 and Dose 2:3 month
Dose 2
Minimum age for Influenza vaccination is 6 months old
10 Influenza
Dose 1 DD/MM/YY Minimum interval to next vaccine dose:
Dose 2 DD/MM/YrYY Age 6 months to 8 years:
Dose 3 -2 dose series 4 weeks for children receiving Influenza vaccination for the first time
-1dose for all other children annually or per season or as recommended
Booster1
Please only input the latest 4 doses during online Age 9-12 years:
-1dose annually or per season or as recommended
applicotion
Pleose fillup Toble 1for any additionol dose(s) taken.
Table 1: Optional Vaccination
Date (DD/MM/YYYY) /Vaccine Name
s/N Immunisation Dose 3 Dose 4 Dose 5
Dose 1 Dose 2

2
1 RoTANIRUS oalalas(goTA Rlalas(RoTATEG)
3
4

6
7

" Please refer to Appendix A for Vaccine Code and Vaccine Name

National Childhood Immunisation Schedule (NCIS)

(from birth to age 17 years, effective from1 November 2020)
Vdoe Brth 2 12 1 16 2-4 5-9 10-11 12-13 13-14 15-17
months Months months months months months years years years years years years

Beclus (almette-Gukrin(8CG) D1

Hepatith B(HepB) D

Dlphthesla, tetaus and ace lular

pertusi (paedlatk) (DTeP)
Tetanus, reduced iphtheria and 82
acelular pertussh (Tdap)
Inctiveted pollovirus (1PV) D1 B2

loemophllus influenioetype b D D2 B1
(Mitb)
Pneurnoocal onjugate D1 D2 81
(PCV10 orPCV13)
Pseunoroal potysaccharide One or two doses for children and adolescents age 2-17 years with specific
(PSV23) medical condition or indkation.
Me des, mumps and rubelMla D1
(MMR)
Varkella (VAR)
Hnan papillomavlrus D1 D2
(4PV2 or HV4) (Females) (Females)
lesfluenza (NI) Annual vaccinaton or per season for all children age 6 months to Annual vaccinatlon or per season for children and adolescents
<S years (6-59 months). age S-17 years with specific nedical conditlon or indication.

Reconmended ages and doses lor all ehlldren Recornnended for persons wlth specific medlcal condtion or indik ation

FOOTNOTES
D1, D2, D3: Dose 1, dose 2, dose 3
B1, B2: 8ooster 1, booster 2

4 "Vaccne Name"refers to a vaccine code or trade name of the vaccine. Examples of voccine code and voccine name con be found in AppendlxA.
7 "Recommended Vaccinatlons"refers to vaccinutions listed in the Singapore Natlonal Childhood immunsiotlone Schedule (NCIS). Information on Singopore Natlonal Childhood immunsldtion &Schedule (NCIS) is available ot
https//www.nithpb.goVsg/nirp/eservdcesfmmunisatlonSchedule

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