IMMUNIZATION RECORD - APPLICANTS UNDER 16 YEARS OF AGE

In Canada it is a provincial requirement that all children attending school to appropriately immunized before
school entry. In order to assist in the school entry and assist in the health of immigrant children, it is strongly
recommended that a record of immunizations received prior to immigration to Canada be created and certified before
leaving for Canada.

This form - Immunization Record Form - wil be issued by the immigration/visa officer handling the immigration
application. It is the applicant’s responsibility to have the form completed and certified by a qualified health
professional before departing for Canada. This form should be presented to the appropriate provincial health authority
before the child registers for school. It is recommended that the original immunization record be retained by the
individual in case of secondary migration.

To be completed and certified for Immigration Applicants to Canada under 16 years of age. Please enter date of
administration in appropriate area. Where not administered, please mark “N.A.”

Family Name Given Name(s) Day/Month/Year

PRIMARY BOOSTER
1st 2nd 3rd 4th 5th
DIPHTHERIA
PERTUSSIS (WHOOPING COUGH)
TETANUS
POLIO
MUMPS
MEASLES (RUBEOLA)
RUBELLA (GERMAN MEASLES)
HAEMOPHILUS INFLUENZA B
B.C.G.
OTHER

I hereby certify that this is a true record of the immunizations received by the above-named.

Signature of qualified health professional Day / Month / Year

Name :

Address :

Professional Designation :