Sistem Informasi Kesehatan Pelabuhan

Balai Kekarantinaan Kesehatan/Rumah Sakit

KKP Kelas I Tanjung Priok

No. Dokumen

K01-102060

Barcode Number

K01-102060

This is to certify that [Name]

FARIZ AL RAHMAT

Date Of Birth

24th June 2002

Sex

Male

Nationality

INDONESIA

National Identification Documents, If Applicable

-

Whose Signature Follows

-

Has on the date indicated been vaccinated or received prophylaxis againts: (name of disease or condition)

YELLOW FEVER

Vaccine or Prophy	Date	Signature and profesional status of supervising clinican	Manufacture and batch no. of vaccine or prophylaxis	Certificate valid until	Official stamp of the administering centre	Disease targeted	Date	Manufacture, brand name and batch no. of vaccine	Next Booster (date)	Official stamp and signature
YELLOW FEVER	7th September 2025	dr. Deddy Ardhiansyah	28062021	-	KKP Kelas I Tanjung Priok	-	-	-	-	-
TYPHIM VI	22nd September 2025	dr. Deddy Ardhiansyah	-	22nd September 2028	KKP Kelas I Tanjung Priok	-	-	-	-	-
CHOLERA	30th September 2025	dr. Deddy Ardhiansyah	-	30th September 2028	KKP Kelas I Tanjung Priok	-	-	-	-	-

International Certificate Vaccination Or Prophylaxis