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定期予防接種予診票交付申請書（高齢者施設等からの複数人分代理申請用）
healthseniors
This application form is used by elderly care facilities and similar organizations to apply for routine vaccination screening questionnaires on behalf of multiple individuals when it is difficult for recipients or their families to apply. It covers vaccinations for elderly influenza and elderly COVID-19. Copies of identification documents for both the recipients and the applicant must be attached.
| What | 高齢者インフルエンザまたは高齢者新型コロナウイルスの定期予防接種予診票の代理交付申請 |
|---|---|
| Who | 高齢者施設等（被接種者本人や家族からの申請が困難な施設関係者など） |
| When | 記載なし |
| Where | 記載なし |
| How | 申請書に被接種者情報、申請者情報（施設名および施設長名）、再発行の理由、希望する予防接種の種類、送付先を記入し、被接種者および申請者の本人確認書類の写しを添付して提出する。 |
| Deadline | 記載なし |
| Contact | 記載なし |
Open the original PDF ↗ 1 pages
Source page: https://www.city.minato.tokyo.jp/hokenyobou/kenko/kenko/yobosesshu/influ.html
Checked 2026-09-13. This page restates the PDF in a fixed structure; nothing is added or removed. Where the PDF does not say, the field reads "not stated". The original Japanese PDF is authoritative — confirm dates and conditions there.