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How to Fill in the Form for the COVID-19 Vaccine Ticket in Japan


How to Fill in the Form for the COVID-19 Vaccine Ticket in Japan

If the vaccination becomes available in your area, the local government will send a “vaccine ticket” (新型コロナワクチンの予診票) to you. Before you can reserve a spot to get the COVID-19 vaccine, you must fill in the form for the vaccine ticket. In this blog, we would love to share with our Smilers how to properly input information and inform you all on what to do in order to get the COVID-19 vaccine.

Table of Contents

1. Confirm if you can get the COVID-19 vaccine or not

Symptoms that appear after getting the COVID-19 vaccine differ from person to person. Some may be affected more severely than others.To see if you’re eligible to get the vaccine and to see the list of possible effects, you can check on Japan’s Ministry of Health website. Due to serious cases arising, we advise you to confirm your health condition before acquiring a reservation for the COVID-19 vaccine.

2. Find a hospital or vaccination site to get the COVID-19 vaccine

After you’ve confirmed your health conditions to get the COVID-19 vaccine, you can proceed to find hospitals, clinics, or vaccination sites that give out the COVID-19 vaccine. For more information and to find your local medical institution that has COVID-19 vaccines, you can visit Japan’s Ministry of Health website (as of October 7, 2021, the web page used to search is no longer available).

3. Fill out the form for the vaccine ticket and make a reservation to get the COVID-19 vaccine

After you’ve found the place where you can get the COVID-19 vaccine, it’s now time to fill out the vaccine ticket form. For guidance, we highlighted the required areas to fill in. For more detailed guidelines, please take a look at the links below for the translated forms.

Translations of Prevaccination Screening Questionnaire for COVID-19 vaccine|Ministry of Health, Labour and Welfare, Government of Japan (mhlw.go.jp)

英語(English) [PDF:243KB]  

アラビア語(Arabic) [PDF:211KB]

中国語(簡体字)(Simplified Chinese) [PDF:143KB] 

中国語(繁体字)(Traditional Chinese) [PDF:214KB]

フランス語(French) [PDF:251KB]

インドネシア語(Indonesian) [PDF:235KB]

クメール語<カンボジア>(Khmer) [PDF:175KB] 

韓国語(Korean) [PDF:411KB]

モンゴル語(Mongolian) [PDF:342KB]

ミャンマー語(Myanmar) [PDF:1,442KB] 

ネパール語(Nepali) [PDF:100KB] 

ポルトガル語(Portuguese) [PDF:274KB]

ロシア語(Russian) [PDF:320KB] 

スペイン語(Spanish) [PDF:242KB]

タガログ語<フィリピン>(Tagalog) [PDF:280KB]

タイ語(Thai) [PDF:249KB]

ベトナム語(Vietnamese) [PDF:321KB]

Original Form
新型コロナワクチン接種の予診票_20210527_Aol (mhlw.go.jp)

1.Write your personal information:

  • Address
  • Full name that appears on your residence card
  • Phone number
  • Birthdate and current age
  • Gender
  • Body temperature before you get the vaccine

2.This section asks you, “Are you receiving the COVID-19 vaccine for the first time?” If “NO”, write the date (MMDD) of your vaccination. 

3.Check the following if you fall into one of the target groups that have a higher priority for this vaccine (e.g., □ medical personnel, etc. □ Person 65 years or older □ Person 60 to 64 years old □ Worker at a senior citizen facility, etc. □ A person with an underlying disease).

4.If you are currently suffering from a disease, check the box of your disease or write the name of it (e.g., □ heart disease □ kidney disease □ liver disease □ blood disease □ that makes it difficult to stop bleeding □ immune deficiency □ other). They are also asking about the treatment method, so you can write the name of the medication you’re currently taking.

5.This section asks, “Have you had a fever or gotten sick in the last month?” If “YES”, name the type of illness you had.

6.You are asked, “Are there any parts of your body that are not feeling well today?” If “YES”, write the name of your condition(s).

7.This section asks, “Have you ever experienced severe allergic symptoms (such as anaphylaxis) from medications or food?” If “YES”, please write the medication or food that caused the problem(s).

8.You are asked, “Have you ever been sick after receiving a vaccine?” If “YES”, please write the type of vaccine and condition that caused you to get sick.

9.You are asked, “Have you had any vaccines within the last two weeks?” If “YES”, write the type of the vaccine and the date of your vaccination.

10.This section confirms whether you agree with getting the COVID-19 vaccine or not. If you want to get the vaccine, check the left box and sign your name with the date you filled up the COVID-19 vaccine ticket form.

11.AFTER you get the vaccine, you will stick the vaccine ticket in the box that’s included in the same envelope. 

Smiles hopes that we all can fight this pandemic together safely. We wish every day that we can soon take off our masks and spread smiles across the world.

Related articles:

COVID-19 Vaccine Update Japan: Q&A’s about Registration, Vaccination Sites, Resources & More

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