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K450@5?R:?J: 0: 0@PPp*PPPPP??&(JPPP@5PPPP:PPPPPPPPP : eP穅纇錱翄f擽纇錱y橆vhNh ITEMS REQUIRED FOR HEALTH CERTIFICATE Form C (耂€(u)(for Reference Only)纇錱錯g ____/____/____ (t^) (g) (錯)Date of Examination ____/____/____(-) ($) (9)鶺 ,g D 檈 ( BASIC DATA) 瀃0寶00纇0錱 (LABORATORY EXAMINATIONS)A. 粸箄蔛穇齎粸箄(螛箄)KN梑SO3?`纇寶JTb剺2枼c蛓翄fProof of Positive Measles and Rubella Antibody Titers or Measles and Rubella Immunization Certificates a.梑SO纇錱Antibody Tests 粸箄梑SOMeasles antibody titers ?3?` Positive ?4?` Negative ?*gnx歔Equivocal  穇齎粸箄(螛箄)梑SORubella antibody titers ?3?` Positive ?4?` Negative ?*gnx歔Equivocal b.剺2枼c蛓翄f Vaccination Certificate (+T玼讉T饄0蛓錯g0蛓USMOb;S^~{鄗0俌纇D東^鰁蛓獈U_ vQ蛓t^劅臺{?Y嶯1乗俌纇D栄g蛓獈U_ 蛓錯gN鶴齎錯g髞\鴙敄2hT錘 N0) (The certificate should include the date of vaccination, and the name of the hospital or clinic administering the vaccine or the signature of the physician administering the vaccine. If the childhood immunization record is submitted, it is important to include the record of the vaccination administered at least one year of age. In addition, if the recent immunization record is submitted, it is important to note that the date of vaccination should be at least two weeks prior to traveling abroad.)?粸箄剺2枼c蛓翄fMeasles Immunization Certificates ?穇齎粸箄(螛箄)剺2枼c蛓翄fRubella Immunization Certificates c. ?蟸;S^膵0O  g蛓亂蘝€ 俧N悳[蛓0(Having contraindications, not suitable for vaccination)B. 鴢钀XIQ纇錱簚觺8hChest8-Ray for Tuberculosis eg陙觺8h舥貧螛i?W:SN\PYu3*Ng錘 N€{槧RZPdk纇錱(Those who arrived from areas at high risk for tuberculosis and have plans to stay in Taiwan for more than three months should undergo chest 8-ray examination.) 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^?`d{?dVD?WD ^?`d{"$勷?dG$UDdVD?WD XD]勷^?`$gdw-*.04>@FLNZ\jl NP逅村舜逅〈舜壌″村村磚`J*jh?h3QB*CJPJUaJph)h{h{B*CJPJaJnHphtH'hw-*h3Q5?*B*CJPJaJph/h{h{5?*B*CJPJaJnHphtH$hw-*h3Q5丅*CJPJaJph,h{h{5丅*CJPJaJnHphtH3h{h{5丅*CJPJQJaJnHo(phtH4h{h{5丅*CJOJPJQJaJnHphtH 0246nvx€HH"H钲钲钆瞵瞵棳棳顒楊o顒蓬垲垲蓬瑮瑮剹m楊U(hTh3QB*CJOJPJQJo(ph%hTh3QB*CJOJPJQJph)h{h{B*CJPJaJnHphtH0h{h{B*CJPJQJaJnHo(phtH*jh?h3QB*CJPJUaJph%h?h3QB*CJPJQJaJph!h?h3QB*CJPJaJph*46prtv|m||$d$$Ifa$gd= d$$Ifgd=vkd$$If4謀?@ D%\   `%4 af4yt Kvxz|~€|m||$d$$Ifa$gd= d$$Ifgd=vkde$$If4謀?@ D%\   `%4 af4yt K€|m||$d$$Ifa$gd= d$$Ifgd=vkd$$If4謀?@ D%\ €€ € `%4 af4yt KHH H"H|m||$d$$Ifa$gd= d$$Ifgd=vkd$$If4謀?@ D%\   `%4 af4yt K Physician ) eq \o\ad(珣b枲尙尯N=|鄗,000000000000)Name  Signature ( Superintendent )錯gDate  / / ,g翄f N*Ng匭 gHeValid for Three Months  D朥_觺8h舥貧裇u噑齎禰b0W:SAppendix: Countries or areas at high risk for tuberculosis'k2mEuropeRomaniaWl欬\歂0Bosnia and Herzegovina鈒痚<\歂Nk峖X錞魚硚0歂2m0歂?+T鏴蟼T€)Asia,West Asia Afghanistan?柼[Wl0Angola塠錞蒪0Armenia歂<\歂0Azerbaijan歂^X躡6q0Bangladesh_[燫蒪齎0Belarus}v腛W痚0BhutanN9N0Brunei Darussalam噀眱0Cambodia靏訵鑋0China'YF?W:S0CongoR済0East Timor (Timor-Leste)N^vl0GeorgiaTN籰歂0Hong Kong 櫃/n0IndiapS0IndonesiapS<\墯N0Iraq O蒪KQ0Kazakhstan萒(凨Q0Kyrgyzstan T\ T痚0Lao People s Democratic Republic頪齎0Latvia蒪1侓~歂0Lithuania藌v枦[0Macau硂钑0Malaysial歟g墯N0Mongolia檮銼0Myanmar8u0Nepal<\蔿\0North KoreaS闂0Pakistan鬩鶺痚fW0Papua New Guinea鬩^歂絶郠匭歂0Philippines騼媉綶0South KoreaWS闂0Russian腛W痚0Sri Lanka痚虘pQaS0TajikistanTX TKQ0Thailand餷齎0TurkmenistanW揯黤0UkraineLNKQpQ0UzbekistanLNyQ+RKQ0Vietnam妽WS0Yemen_N钑0*Ys^ mPacificGuamsQ沑0Kiribati鶺虘鬩痚0Marshall Islandsl毻~\沑0Micronesia芠KQW<\墯N0Niue絶肳0Northern Mariana IslandsSl毺憵N硚沑0Palau^ t0TuvaluT鎡仠0VanuatuN0^?mAfricaAlgeria?\蔛)R歂0Benin峎S0Botswana鈒-g0^ T硚誰"}0Burundifm問0W0Cameroon€U問0Cape Verde 魚穇覊沑0-N^梣Q孴齎Central African Republic0Chad錱穇0CongoR済0Cote d Ivoire (Ivory Coast)褃yr陱鎡0Djibouti T^衏0Equatorial Guinead峉愢Q匭歂0Eritrea凷)R俉歂0Ethiopiac?}詋歂0Gabon燫m_0Gambia 圦詋歂0Ghana鎻硚0Guinea郠匭歂0Guinea-Bissau郠匭歂詋蛜0Kenya瘈歂0LesothoV?}Xb0LiberiaV嵲k^t歂0Madagascarl毦彔R痚燫0Malawil毶bZ0Malil?R0Mauritania踜虘TX<\歂0Moroccoidm錞0Mozambique珒Qh詋KQ0Namibia硚s|詋歂0Niger<\錯0NigeriaHY蔛)R歂0RwandabS塠緩0Sao Tome and Principle #WYnf梘墯N0Senegal^X匭燫\0Sierra Leone顁P[q\0Somalia"}l?R歂0South AfricaWS^0Sudan蟼9N0Swaziland騍鎡NmpQ0TanzaniafW\<\歂0TogoY錞0UgandaLNr^緩0Zambia^嵲k歂0Zimbabwe%m鬩^鏃02mAmericaBolivia籹)R魚歂0Brazil鬩0Dominican RepublicYs|<\燫0Ecuador凷躷Y\0El Salvador(\鎡Y0GuatemalaqS0Wl毶b0Guyana講歂0Haitiwm0W0Honduras廩龕蒪痚0Nicaragua<\燫蒪躷0Panama鬩bl0Paraguay鬩蒪-W0Peru貀仠0Suriname蟼)RWS0鑜觺8h舥貧裇u噑0W:S鹼c觺8h舥裇u噑貧嶯蟢ASN篘鉙40篘剉0W:S0NoteCountries or areas at high risk for tuberculosis refer to countries or areas with a tuberculosis incidence rate that is higher than 40 per 100,000 population. 覻 T'`+R ?7uMale?sYFemaleName____________________Sex珟齆翄W[鱏gq鱏xID No.____________________Passport No.____________________鶴ut^g錯     /     /     齎M|Date of 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