First Schedule
Certificate of unfitness for vaccination (s. 40)
I, the undersigned, certify that in my opinion _____________________ is not now in a fit and proper state to be vaccinated, and I recommend that the vaccination be postponed for six months from this date._________________________________________Medical Practitioner or Public VaccinatorDated this ____________ day of ________________, 20 ____.
Second Schedule
Certificate of insusceptibility to vaccination (s. 41)
I, the undersigned, certify that I have three times unsuccessfully vaccinated ______________________________________ (or that ______________________ has already had smallpox, as the case may be), and I am of opinion that _________________________________ is insusceptible of successful vaccination._________________________________________Medical Practitioner or Public VaccinatorDated this ____________ day of _________________________, 20 ____.
Third Schedule
Certificate of Vaccination (s. 42)
I, the undersigned, certify that _________________________________ has been successfully vaccinated by me._________________________________________Medical Practitioner or Public VaccinatorDated this ____________________ day of ______________________________, 20 ____.