Obrazac broj 1. Stranica 1 KARTON CIJEPLJENE OSOBE Ime, ime oca i prezime Dan, mjesec i godina rođenja

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1 PRILOG Stranica 1 KARTON CIJEPLJENE OSOBE Ime, ime oca i prezime_ Dan, mjesec i godina rođenja Slovo JMBG OIB Adresa (Mjesto, ulica i kbr.) Naziv škole (dječjeg vrtića) Bolest protiv koje se cijepi u slijedu cijepljenja Naziv cjepiva, proizvođač i broj serije cijepljenja Tuberkuloza Tuberkuloza PPD testiranje i eventualno cijepljenje Haemophilus infl. tip B Haemophilus infl. tip B Haemophilus infl. tip B Haemophilus infl. tip B Difterija, tetanus, pertusis Difterija, tetanus, pertusis Difterija, tetanus, pertusis Difterija, tetanus, pertusis Difterija, tetanus, pertusis Difterija, tetanus Difterija, tetanus Difterija, tetanus Tetanus Stranica 2 Bolest protiv koje se cijepi u slijedu cijepljenja Naziv cjepiva, proizvođač i broj serije Ospice, rubeola, parotitis Ospice, rubeola, parotitis Hepatitis B Hepatitis B Hepatitis B cijepljenja Obrazac broj 1 Primjedbe (nuspojava i sl.) Rezultat Mantoux testa Primjedbe (nuspojava i sl.) Ostala cijepljenja

2 Obrazac broj 2 IZVJEŠĆE O NEPOŽELJNIM SPOREDNIM POJAVAMA U PROVEDBI OBVEZNE IMUNIZACIJE PROTIV ZARAZNIH BOLESTI Zdravstvena ustanova Zdravstveni djelatnik u privatnoj praksi Adresa Telefon: Ime, očevo ime, prezime i adresa imunizirane osobe Spol životna dob (naznačiti: mjeseci ili godine) težina (kg) Visina (cm) Vrsta primljenog imunobiološkog preparata (cjepivo, serum, imunoglobulini, naziv preparata): Proizvođač proizvodnje serija broj primjen primljena doza (u slijedu cijepljenja: prva, druga, treća...) Način primjene (i.m, i.c., s.c.) Količina (ml) Da li je i koliko doza tog preparata osoba u životu primila, koje godine i prethodne reakcije Prethodne reakcije na druge imunobiološke preparate (preparat, reakcija) Oboljenja u času primanja preparata: koja su bila poznata liječniku (cjepitelju) koja nisu bila poznata liječniku (cjepitelju) Nepoželjna sporedna pojava: dijagnoza datum početka opis (tok, simptomi) Primljena terapija Ishod bolesti (Ozdravljenje, trajno oštećenje, smrt, nepoznato) *) Nepoželjnom sporednom pojavom u svrhu ovog izvještaja smatra se svaka neoubičajena reakcija na imunobiološki preparat, odnosno svaka komplikacija. Obrazac broj 3 Cjepitelj (Ime zdravstvenog djelatnika) Općina Ustanova (privatnik, dom zdravlja, zavod za javno zdravstvo) Županija Adresa Godišnji plan imunizacije za godinu Cijepit će se protiv Difterije, tetanusa i pertusisa (DTP) DTP 1. DTP 2. Difterije i tetanusa (Td) docjepljivanje 1. Difterije i tetanusa (Td) docjepljivanje 2. Difterije i tetanusa (Td) docjepljivanje 3. Tetanusa docjepljivanje a a docjepljivanje 1. a docjepljivanje 2. a docjepljivanje 3. Haemophilusa influenzae tip B* Potpuno primarno (sve tri doze) Haemophilusa influenzae tip B docjepljivanje Ospica, rubeole i parotitisa primarno Ospica, rubeole i parotitisa docjepljivanje Tuberkuloze (primarno)* Hepatitis B dojenčad (potpuno)* Hepatitisa B školska djeca (potpuno)* broj osoba *Upisuje se samo onaj broj osoba koje će tijekom godine potpuno dovršiti primovakcinaciju, a ne i one koje će je tek započeti, odnosno one koje je neće moći dovršiti. Potpis cjepitelja Upotrijebite drugu stranu za dodatne podatke i zapažanja Mjesto i datum Potpis odgovorne osobe:

3 Obrazac broj 4 Veličina 210x150 mm Redni broj POZIV Prezime i ime roditelja / skrbnika Adresa Redni broj U Dana godine Pozivamo Vas da dovedete dijete (ime i prezime) god. roenja na cijepljenje protiv TUBERKULOZE; DIFTERIJE; TETANUSA; HRIPAVCA; DJEJE PARALIZE; OSPICA; CRVENKE; ZAUŠNJAKA; HAEMOFILUSA INFL. B; HEPATITISA Bkoje e se obavljati dana u sati, mjesto ulica kbr. Cijepljnje je obavezno. Spreavanje ovih bolesti je za dobrobit Vašeg djeteta. Mjestoidatum: POTVRUJEM primitak poziva za cijepljenje protiv tuberkuloze, difterije, tetanusa, hripavca, djeje paralize, ospica, crvenke, zaušnjaka, haemofilusa infl. tip B i hepatitisa B* uz razumijevanje da je cijepljenje obavezno. Potpis primatelja: IZVJEŠTAJ o neizvršenoj dostavi Po izjavi (adresa) naslovnik na naznaenoj adresi je nepoznat-odselio u OBAVIJEST RODITELJIMA OBVEZNICIMA U mnogim zemljama, pa tako i kod nas, cijepljenje protiv difterije, tetanusa, hripavca, djeje paralize (poliomijelitisa), ospica, crvenke, zaušnjaka, haemofilusa infl. tip B i hepatitisa B obveza je za svakog graanina. Naime, cijepljenjem protiv tih bolesti kroz niz godina neke se uspjelo iskorijeniti djeju paralizu i difteriju, ospice i rubelu eliminirati, druge znaajno prorijediti tetanus, a tree pak ublažiti hripavac. Isto tako svaka osoba pravilno cijepljena protiv tetanusa pri ranjavanju je potpuno zaštiena od ove nadasve smrtonosne bolesti. Zato, roditelji obveznici bez oklijevanja pristupite cijepljenju. : U nekim razvijenim zemljama cijepljenje se ne smatra obavezom, nego preporukom. Meutim, u tim zemljama dijete ne može krenuti u djeji vrti niti u školu (koja je zakonska obaveza) ako nije prema preporukama cijepljeno.

4 Stranica 1. Obrazac broj 5 Veličina 9,5 x 14,0 cm Tvrdi papir Stranica 4. Cijepljenje protiv djeje paralize Vaccination against poliomyelitis Republika Hrvatska Republic of Croatia Proizvoa Potpis i peat lijenika (grb) Ministarstvo zdravlja Misnistry of Health Iskaznica imunizacije Certificates of immunization Stranica 5. Cijepljenje protiv H. influenzae tipa B bolesti Vaccination against H. influenzae type B disease Stranica 2. Tuberkulinsko testiranje i cijepljenje protiv tuberkuloze Tuberculin Testing and Vaccination Against Tuberculosis Proizvoa Potpis i peat lijenika /PPD Nature of product Rezultat Result Proizvoa Batch no. Potpis i peat lijenika Signature and stamp Stranica 3. Cijepljenje protiv difterije, tetanusa i hripavca Vaccination against diphtheria, tetanus and pertusisis Stranica 6. Cijepljenje protiv ospica, parotitisa i rubele Vaccination against measles, mumps and rubella Proizvoa Potpis i peat lijenika Proizvoa Potpis i peat lijenika

5 Stranica 7. Cijepljenje protiv hepatitisa B Vaccination against hepatitis B Stranica 10. Primjena imunoglobulina Administration of immunoglobulins Proizvoa Potpis i peat lijenika Dijagnoza Diagnosis Potpis i peat lijenika Stranica 8. Ostala cijepljenja Other vaccinations Stranica 11. Proizvoa Potpis i peat lijenika Remarks Stranica 9. Ostala cijepljenja Other vaccinations Preosjetljivost na cjepiva Allergy to vaccines Proizvoa Potpis i peat lijenika Preosjetljivostnalijekove Allergytodrugs

6 Stranica 12. Podatke u iskaznicu imunizacije unosi doktor medicine koji cijepi/nadzire cijepljenje/imunizaciju Information is entered into the Certificates of immunization booklet by the physician who performs/supervises vaccination. Ako osoba koja se cijepi nema kod sebe iskaznicu imunizacije, treba joj se izdati nova In case the vaccinee does not have the Certificates of immunization booklet during an immunization session, he/she should be issued a new one a a docjepljivanje 1. a docjepljivanje 2. a docjepljivanje 3. Haemophilusa influenzae tip B Haemophilusa influenzae tip B docjepljivanje Ospica, rubeole i parotitisa primarno Ospica, rubeole i parotitisa docjepljivanje Tuberkuloze (primarno) Tuberkuloze cijepljenje nakon PPD testiranja (tuberkulin negativne osobe) Hepatitis B dojenčad (potpuno)* Hepatitisa B školska djeca (potpuno)* Cjepljenik/roditelj/staratelj je dužan uvati iskaznicu imunizacije i ponijeti na svako cijepljenje/imunizaciju The vaccinee/parent/guardian should have the Certificates of immunization booklet in keeping and bring it to every immunization session Obrazac broj 6 Cjepitelj Općina (Ime zdravstvenog djelatnika) Ustanova Županija (privatnik, dom zdravlja, zavod za javno zdravstvo) Adresa Cijepljeno je protiv Godišnje izvješće o izvršenim obveznim imunizacijama u godini Difterije, tetanusa i pertusisa (DTP) DTP 1. DTP 2. Difterije i tetanusa (Td) docjepljivanje 1. Difterije i tetanusa (Td) docjepljivanje 2. Difterije i tetanusa (Td) docjepljivanje 3. Tetanusa docjepljivanje broj osoba od predviđenih % *Upisuje se samo onaj broj osoba koje su tijekom godine potpuno dovršile primovakcinaciju, bilo da su primile sve tri doze, bilo da su primile zaostalu jednu ili dvije doze iz prethodne godine, a ne i one koje su tek započele seriju od tri doze. Mjesto i datum Potpis odgovorne osobe: HRVATSKI ZAVOD ZA ZDRAVSTVENO OSIGURANJE 2323 Na osnovi članka 103. stavak 1. točke 4. Zakona o obveznom zdravstvenom osiguranju (»Narodne novine«broj 80/13.) i članka 26. točka 8. Statuta Hrvatskog zavoda za zdravstveno osiguranje (»Narodne novine«broj 18/09., 33/10., 8/11. i 18/13.) Upravno vijeće Hrvatskog zavoda za zdravstveno osiguranje na 41. sjednici održanoj 24. srpnja godine donijelo je PRAVILNIK O IZMJENI PRAVILNIKA O PRAVIMA, UVJETIMA I NAČINU OSTVARIVANJA PRAVA IZ OBVEZNOG ZDRAVSTVENOG OSIGURANJA Članak 1. U Pravilniku o pravima, uvjetima i načinu ostvarivanja prava iz obveznog zdravstvenog osiguranja (»Narodne novine«broj 67/09., 116/09., 4/10., 13/10., 88/10., 1/11., , 87/11., 137/11., 39/12., 69/12., 126/12., 38/13. i 77/13.) u članku 16. stavku 3. iza riječi:»europske unije«briše se zarez i riječi:»državama članicama Europskog gospodarskog prostora i Švicarskoj«. Članak 2. Tiskanica uputnice iz članka 50. stavka 1. mijenja se i sastavni je dio ovog Pravilnika.

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