Panchayat:Repo18/vol2-page0108

108 THE TRAVANCORE - COCHIN PUBLIC HEALTH ACT, 1955 FORM - I


which may extend to three months or with fine which may extend to one hundred rupees or with both.

                                                                           FORM No.I
                                                                  Notice for Vaccination
                                                                     [See Rule 2 (iii)]

Sri ...--------- (Name)........ . . . . . . . . . . . . . . . . . . . . residing in .............. House ...................... Kara ..... Pakuthy .................... Taluk ................... District ......................... is hereby informed that he/his son/daughter............................... aged ..................................... (in the case of minor children) ........................................................ shall appear/be produced for inspection and shall be subject to vaccination/re-vaccination for protection against Smallpox On..................- (date) at .................... (time)................... at ............................... (place) failing which he shall be liable for punishment under the rules.


Station............................ Signature.................................. Date.................................. Designation...............................


                                                                                  FORM NO. II
                                                       Certificate of Postponement of Vaccination 
                                                                              See Rule 4 (i))


The child"/person.................... aged...................... residing at.................................. is not in a fit state for vaccination for a period of............. months on account of ..............


Station.............................. Signature.................................. Date.................................. Designation...............................


"Note:- In the case of child, note name of parent or guardian of the child.


                                                                            FORM NO. III 
                                                       Vaccination Certificate
                                                              
                                                                  [See Rule 5 (ii))


It is hereby certified that child/person ........................ aged ......... residing at............. has been ............. vaccinated/re-vaccinated on........................ and bears ................... marks.


Station.............................. Signature.................. Date.................................. Designation...............

"In the case of child, name of parent or guardian of the child.

                                                                                   FORM No. IV 
                                                                               Notice for Inspection 


                                                                                    See Rule 9 (i)


As it is known and there is every reason to believe that you/your son/your daughter ........................... aged ........................... residing...................... in........................... (Ward) - - - - - - - - - - - Kara .................. Pakuthy .............. Taluk .....................require/requires protection from smallpox, you are therefore requested to produces to be present, in the house for inspection during my visit at................ hour on.................... date................ you will furnish Such necessary information as to age, parentage, place of birth and the duration of the residence in the area etc., relating to you/your child.

        You will be subject to prosecution under the rules in case you fail to comply with the notice. 

Station.............................. Signature.................................... Date.................................. Designation............. . . . . . . . . . . . . . . .