英語版
Vaccine Screening Questionnaire for [] (infant/schoolchild)

Form 2

Body temperature before interview

Degrees

Address
Child’s NameM
F

Parent/Guardian’s Name

Born onAge (Birth date

Questionnaire for Vaccination

/
years

AnswerHave you read the document (sent to you previously by the municipal office) explaining thevaccination that will be administered today?

Yes

No

Yes
Yes

No
No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Where relevant, did the doctor who manages the above disease agree with today's vaccination?

Yes

No

Has the child had a seizure (spasm or fit) in the past?
If so, at what age did it occur? (

Yes

No

If you answered “yes” to the preceding question, did the child have a fever at that time?

Yes

No

Has the child ever had a rash or urticaria (hives or ‘nettle rash’) as a reaction to medications orfood or become ill after eating certain foods or receiving certain medications?

Yes

No

Does the child have a family member or relative with a congenital immunodeficiency?

Yes

No

Yes

No

Has any family member or relative of the child had a serious reaction to a vaccine in the past?

Yes

No

Has the child received a transfusion of blood or blood products or been given a medicine
called gamma globulin in the past 6 months?

Yes

No

Do you have any questions about today’s vaccination?

Yes

No

Please answer the following questions about the child.
Did the child have any abnormal findings at delivery?
Birth Weight()g
Did the child have any abnormal findings after birth?
Was any abnormality identified at an infant health check?
Is the child sick today?
If so, describe the nature of the illness. ()

Has the child been ill in the past month?
Disease name ()
Has any family member or friend of the child had measles, rubella, chickenpox or mumps inthe past month?
Disease name ()
Has the child been exposed to anyone with tuberculosis (including family members)?
Has the child been vaccinated in the past month?
Vaccine name ()
Does the child have a congenital anomaly, heart, kidney, liver, central nerve disease, immune
deficiency, or any other diseases for which you have consulted a doctor?
Disease name ())

Has the child had a serious reaction to a vaccine in the past?
Vaccine name ()/(d/m/y)months)Doctor’s comment

Doctor’s comment
Based on the above answers and the results of interview, I have decided that the child ( can / should not ) receive a vaccination today.
I have explained to the parent/guardian the information concerning the benefits and side effects of vaccination and the support provided to people
who have had adverse events associated with vaccination.
Signature or Name and Seal of Doctor:
This screening questionnaire is used to improve the safety of vaccination. The child has been interviewed by the doctor, and information
concerning the benefits, objectives, and risks (including serious side effects) of vaccination has been explained to me by the doctor, as has thenature of support provided if adverse events occur. I believe that I understand this information.
I ( do / do not )* give consent for the child to be vaccinated. * Please circle your choice.
I understand the above and agree that this questionnaire can be submitted to the municipal office.
Signature of Parent / Guardian:
Vaccine Name
Vaccine Name
Lot Number[Caution] Confirm that the expiration date of
the vaccine is valid.

DosageInstitution / Doctor Name / Date Administered* Vaccination method
mL

Institution:
Doctor Name:
Date Administered://(d/m/y)[Note] Gamma globulin is a blood product that is injected to prevent infections, such as type A hepatitis, and to treat severe infections. Certain vaccines(for example, measles vaccine) are occasionally less effective in people who have received this product in the preceding 3 to 6 months.
* For BCG vaccination, enter “percutaneous injection at the prescribed dose using an apparatus with multiple needles for BCG” etc., and for 5-type combination
vaccine or pneumococcal 15-valent conjugate vaccine, enter “subcutaneous or intramuscular injections”, respectively.

英語版
Vaccine Screening Questionnaire for Human Papilloma Virus Infection

Form 3

Body temperature before interview

Degrees

Address
Patient’s NameM
F

Parent/Guardian’s Name*

Born onAge (Birth date

/
years

/

(d/m/y)months)* Parent/Guardian's Name is not necessary if the patient is 16 years or older.

Questionnaire for Vaccination

AnswerHave you read the document (sent to you previously by the municipal office) explaining thevaccination that will be administered today?

Yes

Doctor’s comment
NoNo, this is the 1st dose.

Has the patient received this vaccination before?

Yes, this is the 2nd dose.
Yes, this is the 3rd dose.

If “yes,” please enter the type of vaccine, the date received, and the patient’s age at
the time of vaccination.
[Caution 1] Circle one of the following vaccines: (1) Cervarix (bivalent); (2) Gardasil (quadrivalent);(3) Silgard 9 (9-valent); (4) Other.
[Caution 2] In the case of (3) Silgard 9 (9-valent), a two-dose regimen can also be followed, consistingof the first dose being received by age 14 and the second after an interval of at least 5 months.
[Caution 3] The parent/guardian, patient, and/or doctor should strive to identify the vaccine received.
If records cannot be retrieved and the vaccine cannot be identified, the doctor is to enter“Unknown.”

(

1st
dose

/

/

)

Has the patient been vaccinated in the past month?
Vaccine name (

)

/

,

(1) / (2) / (3)

Yes

No

Yes

No

Yes

No

Does the patient have a congenital anomaly, heart, kidney, liver, central nerve disease,immune deficiency, or any other diseases for which you have consulted a doctor?
Disease name (
)

Yes

No

Where relevant, did the doctor who manages the above disease agree with today's vaccination?

Yes

No

Has the patient had a seizure (spasm or fit) in the past?
If so, at what age did it occur? (

Yes

No

)

If you answered “yes” to the preceding question, did the person have a fever at that time?

Yes

No

Has the patient ever had a rash or urticaria (hives or ‘nettle rash’) as a reaction to medications
or food or become ill after eating certain foods or receiving certain medications?

Yes

No

Does the patient have a family member or relative with a congenital immunodeficiency?

Yes

No

Has the patient had a serious reaction to a vaccine in the past?

Yes

No

Has any family member or relative of the patient had a serious reaction to a vaccine in the past?

Yes

No

Is there a chance the child could become pregnant (for example, has menstruation been
delayed or has a period been missed)?
[Caution] Strict attention should be paid to vaccinations for pregnant women.

Yes

No

Do you have any questions about today’s vaccination?

Yes

No

Vaccine name ()(1) / (2) / (3) / (4)[Caution] Circle one of the following vaccines: (1) Cervarix (bivalent); (2) Gardasil (quadrivalent); (3)Silgard 9 (9-valent).

Has the patient been ill in the past month?
Disease name ()(d/m/y, age)

Which vaccine do you wish the patient to receive today?

),(1) / (2) / (3) / (4)

(

2nd
dose

Is the patient sick today?
If so, please describe in detail. (/(d/m/y, age))

Doctor’s comment
Based on the above answers and the results of interview, I have decided that the patient ( can / should not ) receive a vaccination today.
I have explained to the patient herself (or the parent/guardian if the patient is under 16 years of age) the information concerning the benefits and adverse
reactions of vaccination and the support provided by Relief System for Injury to Health with Vaccination.
Signature or Name and Seal of Doctor:
This screening questionnaire is used to improve the safety of vaccination. The patient has been interviewed by the doctor, and information concerning
the benefits, objectives, and risks (including serious side effects) of vaccination has been explained to me by the doctor, as has the nature of support
provided if adverse events occur. I believe that I understand this information.
I ( do / do not )* give consent for the patient to be vaccinated.
Please circle your choice.
I understand the above and agree that this questionnaire can be submitted to the municipal office.
Signature of the parent/guardian or the patient herself:(*Signature of the parent/guardian is necessary, if the patient is under 16 years of age)
Vaccine Name
Vaccine Name
Lot Number[Caution] Confirm that the expiration date of
the vaccine is valid.

DosageInstitution / Doctor Name / Date Administered

Intramuscular injection
0.5 mL

Institution:
Doctor Name:
Date Administered://(d/m/y)英語版
Vaccine Screening Questionnaire for Human Papilloma Virus Infection(For child not accompanied by parent / guardian)Form 4

Explanation prior to vaccination against human papilloma virus infection

For the parent/guardian: Please be sure to read this document.

* [For the parent/guardian of a child for vaccination who is at the age corresponding from the sixth grade ofelementary school to the first grade of high school (except for children aged 16 or older)]The parent/guardian was previously required to accompany their child who was receiving a vaccination; however, onlyin the case of vaccination against human papilloma virus infection for children aged 13 years or older (from the first grade ofjunior high school to the first grade of high school (except for children aged 16 or older)), can such children receive vaccines
despite not being accompanied by their parent/guardian, provided the parent/guardian has read, understood, and signed thisdocument permitting their child to be vaccinated.
(Please make sure your child brings this document on the day of vaccination.)
Before signing this screening questionnaire, if you have any questions about the vaccination, please consult your doctor,
healthcare center, or the municipal office in charge of vaccination so that you fully understand the benefits and risks ofvaccination before making a decision about vaccination.
1 Symptoms of human papilloma virus (HPV) infection
Human papilloma virus, a virus which can infect the skin and mucosa, is classified into more than 100 types. Viruses infecting the
mucosa mainly invade genital mucosa through a small wound on the mucous membrane caused by sexual intercourse. More than 50% of
women abroad with intercourse experience are estimated to be infected by these viruses at least once in their life.
Of HPV infecting the mucosa, at least 15 types are detected in cervical cancer and called "high-risk HPV". Two particularly highrisk HPV, Type 16 and 18, are frequently detected and studies indicate that the two viruses were involved in about 70% of cervical cancer
cases abroad. In addition to cervical cancer, at least 90% of anal cancer and 40% of vaginal, vulvar and penile cancer are suspected to beconnected with the two viruses abroad. Viruses not classified into high-risk categories are confirmed to cause condyloma acuminatum, abenign genital wart.
2 Benefits and side effects of vaccination
Vaccine includes viral components of several types of human papilloma viruses (HPVs) and vaccinated children acquire immunity tothese viruses. A child who is immune is protected from HPVs.
However, vaccination occasionally causes mild side effects. Vaccination very rarely causes serious side effects. Reactions sometimes
seen after vaccination are as follows.
Main side effects of HPV vaccine
Main side effects include fever and local reactions (pain, erythema and swelling). Syncope due to pain and psychogenic reaction
induced by injection sometimes occur after vaccination. To prevent falling down due to syncope, vaccinated children should be seated on asofa and observed for about 30 minutes.
On rare occasions serious side effects have been reported, including an anaphylactic reaction (even shock, hives, and difficulty
breathing), Guillain-Barre syndrome, thrombocytopenic purpura (bleeding into the skin, from the nose and oral mucosa) and acutedisseminated encephalomyelitis (ADEM).
* For details, please refer to your municipality's website or information leaflet mailed individually.
3 Systems to support people with adverse events associated with vaccination○ A person with side effects caused by routine vaccination who requires medical treatment or whose ability to perform normal daily
activities is impaired due to injury can be compensated by the government according to the Preventive Vaccination Law.
○ The compensation consists of payment of medical expenses, medical benefits, an annuity for disabled children, a disability annuity,
lump-sum death benefits, and funeral expenses, which are classified by law according to the severity of the injury. Respective
compensation is paid according to the provisions of the law. All compensation, except lump-sum death benefits and funeral expenses, iscontinuously paid until the completion of treatment or the improvement in health.
○ Compensation is paid to the patient after the relevant injury is certified by the governmental review committee to be caused by
vaccination. This committee comprises specialists in vaccination, infectious medicine, law, and other relevant disciplines, who discuss
the causal relationship of the relevant injury with vaccination, that is, whether the relevant injury is caused by vaccination or other factors(infection before or after vaccination, or other causes).
* If you believe you need to submit an application for compensation, consult the doctor who interviewed your child before vaccination, thehealthcare center, or the municipal office in charge of vaccination.

英語版
4 Cautions for vaccination
Vaccination should generally be given to a child in good health. If your child is unwell, please consult your doctor and decide
whether your child should be vaccinated.
When your child meets any of the following criteria, she cannot receive a vaccination.
1) Obvious fever (37.5°C or higher)
2) Severe acute illness
3) A history of anaphylaxis caused by any component of the vaccine preparation
4) Other conditions that a doctor considers inappropriate
If your child is pregnant, she should not be vaccinated.

For the parent/guardian: Please be sure to read this following.

After carefully reading and fully understanding the above, please decide whether or not to have your child vaccinated. If
you decide on vaccination, please sign the following, in the column for parent/guardian. (Without your signature, your childis not permitted to receive a vaccination if she is under 16 years of age.)
If you do not want your child vaccinated, you do not need to sign.
I have read the explanation for vaccination against human papilloma virus infection and I understand the benefits andrisks of serious side effects due to vaccines, as well as the relief system for supporting people who sustain a health injury
caused by vaccination. Considering these issues, I agree to have my child vaccinated.
I understand that this document has been drawn up to help parents and guardians understand vaccination thoroughly andagree that this form can be submitted to the municipal office.
Signature of Parent / Guardian:
Address:
Emergency contact number:		

* This form is necessary for vaccination against human papilloma virus infection when a child is not accompanied by parent/
guardian. Make sure your child submits this form if she is under 16 years old and unaccompanied when receiving thevaccination.
Without your signature on the form, your child is not permitted to receive a vaccination if she is under 16 years of age.

英語版
Screening Questionnaire
Body temperature before interview

Degrees

Address
M
F

Child’s Name

Born onAge (Birth date

Questionnaire for Vaccination

/
years

AnswerHave you read the document (sent to you previously by the municipal office) explaining thevaccination that will be administered today?

Yes/(d/m/y)months)Doctor's comment
NoNo, this is the 1st dose.

Has the patient received this vaccination before?

Yes, this is the 2nd dose.
Yes, this is the 3rd dose.

If “yes,” please enter the type of vaccine, the date received, and the patient’s age at
the time of vaccination.

[Caution 1] Circle one of the following vaccines: (1) Cervarix (bivalent); (2) Gardasil(quadrivalent); (3) Silgard 9 (9-valent); (4) Other.
[Caution 2] In the case of (3) Silgard 9 (9-valent), a two-dose regimen can also be followed, consistingof the first dose being received by age 14 and the second after an interval of at least 5 months.
[Caution 3] The parent/guardian, patient, and/or doctor should strive to identify the vaccine received.
If records cannot be retrieved and the vaccine cannot be identified, the doctor is to enter“Unknown.”

(

1st

(

Has the child been ill in the past month?
Disease name (

)

/

/

,

(1) / (2) / (3)

No

Yes

No

Yes

No

Does the child have a congenital anomaly, heart, kidney, liver, central nerve disease,immune deficiency, or any other diseases for which you have consulted a doctor?
Disease name (
)

Yes

No

Where relevant, did the doctor who manages the above disease agree with today's vaccination?

Yes

No

Has the child had a seizure (spasm or fit) in the past?
If so, at what age did it occur? (

Yes

No

If you answered “yes” to the preceding question, did the child have a fever at that time?

Yes

No

Has the child ever had a rash or urticaria (hives or ‘nettle rash’) as a reaction to medications
or food or become ill after eating certain foods or receiving certain medications?

Yes

No

Does the child have a family member or relative with a congenital immunodeficiency?

Yes

No

Yes

No

Has any family member or relative of the child had a serious reaction to a vaccine in the past?

Yes

No

Is there a chance she is pregnant (for example, has menstruation been delayed, or has aperiod been missed)?

Yes

No

)

)

)

Has the child had a serious reaction to a vaccine in the past?
Vaccine name ()(1) / (2) / (3) / (4)Yes

Has the child been vaccinated in the past month?
Vaccine name ()(d/m/y, age)

[Caution] Circle one of the following vaccines: (1) Cervarix (bivalent); (2) Gardasil (quadrivalent); (3)Silgard 9 (9-valent).

),(1) / (2) / (3) / (4)Which vaccine do you wish the patient to receive today?
Is the child sick today?
If so, describe the nature of the illness. (/(d/m/y, age)

dose

2nd
dose

/

)

[Caution] Strict attention should be paid to vaccinations for pregnant women.

This screening questionnaire is used to improve the safety of vaccination. Do you agree to the vaccination of your child, taking into consideration
past illnesses and how they are today?
I ( do / do not )* agree to have the child vaccinated. * Please circle your choice.
I understand the above and agree that this questionnaire can be submitted to the municipal office.
Signature of Parent / Guardian:Doctor’s comment
Based on the above answers and the results of the interview, I have decided that the patient ( can / should not ) receive a vaccination today.
I have explained to the patient herself the information concerning the benefits and side effects of vaccination and the support provided to people
who have had adverse events associated with vaccination.
Signature or Name and Seal of Doctor:
Vaccine Name
Vaccine Name
Lot Number[Caution] Confirm that the expiration date of
the vaccine is valid.

DosageInstitution / Doctor Name / Date Administered

Intramuscular injection
0.5 mL

Institution:
Doctor Name:
Date Administered://(d/m/y)英語版
Form 8Hepatitis B Vaccine Screening Questionnaire
Body temperature before interview
Address
Child’s Name
Parent/Guardian’s Name

M
F

Born onAge (Birth date

Questionnaire for Vaccination

/
/
years

AnswerHave you read the document (sent to you previously by the municipal office) explaining thevaccination that will be administered today?

Yes

No

Yes
Yes

No
No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Degrees(d/m/y)months)Doctor’s comment

Please answer the following questions about the child.
Birth Weight()g

Did the child have any abnormal findings at delivery?
Did the child have any abnormal findings after birth?

Was any abnormality identified at an infant health check?
Is the child sick today?
If so, describe the nature of the illness. ()
Has the child been ill in the past month?
Disease name ()
Has any family member or friend of the child had measles, rubella, chickenpox or mumps in thepast month?
Disease name ()
Has the child been vaccinated in the past month?
Vaccine name ()
Does the child have a congenital anomaly, heart, kidney, liver, central nerve disease, immune
deficiency, or any other diseases for which you have consulted a doctor?
Disease name ()

Where relevant, did the doctor who manages the above disease agree with today's vaccination?
Has the child had a seizure (spasm or fit) in the past?
If so, at what age did it occur? ()

If you answered “yes” to the preceding question, did the child have a fever at that time?

Yes

No

Has the child ever had a rash or urticaria (hives or ‘nettle rash’) as a reaction to medications orfood or become ill after eating certain foods or receiving certain medications?

Yes

No

Does the child have a family member or relative with a congenital immunodeficiency?

Yes

No

Yes

No

Has any family member or relative of the child had a serious reaction to a vaccine in the past?

Yes

No

Has the child received a transfusion of blood or blood products or been given a medicine called
gamma globulin in the past 6 months?

Yes

No

Yes

No

Yes

No

Has the child had a serious reaction to a vaccine in the past?
Vaccine name ()

Did the child receive the hepatitis B vaccine after birth as part of the mother-to-infant transmission
prevention program?
Do you have any questions about today’s vaccination?

Doctor’s comment
Based on the above answers and the results of interview, I have decided that the child ( can / should not ) receive a vaccination today.
I have explained to the parent/guardian the information concerning the benefits and side effects of vaccination and the support provided to people whohave had adverse events associated with vaccination.
Signature or Name and Seal of Doctor:
This screening questionnaire is used to improve the safety of vaccination. The child has been interviewed by the doctor, and information concerning
the benefits, objectives, and risks (including serious side effects) of vaccination has been explained to me by the doctor, as has the nature of support
provided if adverse events occur. I believe that I understand this information.
I ( do / do not )* give consent for the child to be vaccinated. * Please circle your choice.
I understand the above and agree that this questionnaire can be submitted to the municipal office.
Signature of Parent / Guardian:

Vaccine Name
Vaccine Name
Lot Number[Caution] Confirm that the expiration date of thevaccine is valid.

DosageInstitution / Doctor Name / Date Administered* (Subcutaneous injection)

Institution:
Doctor Name:mL

Date Administered://(d/m/y)ⱥㄒ∧Form 10

Rotavirus Vaccine Screening Questionnaire/

Date

Parent/guardian: Please fill out the bolded fields.

/

Pre-examtemperature

Addressdegrees (include decimal)–

Phone no.
Child’s name

M / F

–

/

Child’s dateof birth

Parent/guardian’s
name(YYYY/MM/DD)

/

(Age:

(YYYY/MM/DD)
weeks

days)

For age in weeks and days, count the day after the date of birth as day 1.

Field for medical
institution to enter(Mark a ;)If this is the first vaccination, have you
confirmed that the child is not older than
14 weeks and 6 days as of today?
Questionnaire

Doctor’scomment

AnswerWhich vaccination will your child receive today?

1st

2nd

Please write the date(s) of the vaccination(s) your child has received so far (answer only if this is your child’s 2nd or 3rd
vaccination).

1st

/

/

(YYY/MM/DD)

2nd

/

/

(YYY/MM/DD)

Note: Confirm that at least 27 days have passed since your child’s last rotavirus vaccination.

3rd

Have you read the document provided by the municipal office explaining the vaccination that will be administered today?

Yes

No

Do you understand the benefits and side effects of the vaccination that will be administered today?

Yes

No

Were you provided with information concerning intussusception, and did you understand that information?

Yes

No

Were there any abnormalities at the time of delivery?

Yes

No

Have there been any abnormalities after birth?

Yes

No

Have any abnormalities been identified in an infant health exam?

Yes

No

Yes

No

Yes

No

Has any family member or friend of the child had measles, rubella, chickenpox, or mumps in the past month?
Name of illness:

Yes

No

Has your child been vaccinated within the past month?
Vaccine:

Yes

No

Yes

No

Yes

No

Does your child have a congenital anomaly; gastrointestinal disorder; heart, kidney, liver, blood, or central nervous
disease; or any other diseases for which you have consulted a doctor? Name of illness:

Yes

No

If you answered yes to the previous question, have you been told by the doctor whom your child is seeing for thatdisease that your child may receive today's vaccination?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Has a close relative of your child been diagnosed with a congenital immunodeficiency?

Yes

No

Has a close relative of your child ever felt ill after receiving a vaccination?

Yes

No

To date, has your child received a blood transfusion or been injected with gamma globulin?

Yes

No

Do you have any questions about today’s vaccination?

Yes

No

The following questions concern your child’s growth and development.
Birth weight:g

Is your child experiencing any illness or does your child feel unwell today?
Please describe the symptoms:
Has your child been sick within the last month?
Name of illness:

Date:(YYYY/MM/DD)

Has your child experienced intussusception before? Or does your child have an untreated congenital abnormality of thegastrointestinal tract?
Note: If yes, your child cannot receive the rotavirus vaccine.

Has your child been diagnosed with immunodeficiency? Or has your child experienced repeated diarrhea, repeated
infections such as pneumonia or middle ear infections, or had difficulty gaining weight?
Note: If yes, your child may not be able to receive the rotavirus vaccine.

Has your child had a seizure (spasm or fit) in the past? If so, at around how many months of age:monthsIf you answered yes to the previous question, did your child have a fever at that time?
Has your child ever had a rash or hives or become ill after eating certain foods or receiving certain medications?
If you answered yes to the previous question, name of medication/food:
To date, has your child ever felt ill after receiving a vaccination?
If you answered yes to the previous question, name of vaccine:
Did the mother take medication which suppresses the immune system while pregnant with the child?
If you answered yes to the previous question, name of medication:

Field for doctor to enter
Based on the above questionnaire and the results of the medical examination, I have decided that the child (can / should not) receive today's vaccination.
I have explained to the parent/guardian the information concerning the benefits and side effects of vaccination (particularly intussusception) and the Relief System for
Injury to Health with Vaccination.
Signature or name and seal of doctor:
Field for parent/guardian to enter
My child has been examined by and I have been provided with information by the doctor. I understand the benefits, objectives, possibility of serious side effects(particularly intussusception), and information concerning the Relief System for Injury to Health with Vaccination, and accordingly I (do / do not)* give consent for mychild to be vaccinated.
Please circle your choice.
I understand that the purpose of the questionnaire is to ensure the safety of vaccinations and I agree that this questionnaire can be submitted to the municipal office.
Signature of parent/guardian:
Vaccine used
Vaccine name:
Lot no.:Warning: Confirm that expiration date of vaccine is valid

DosageOral vaccination
RotaTeq®
2 ml

Rotarix®
1.5 mlPlace of vaccination/doctor's name/date of vaccination
Place of vaccination:
Doctor’s name:Date of vaccination://(YYYY/MM/DD)