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VACCINE INJURY
SECTION A
CONTACT INFORMATION / GENERAL INFORMATION
WHO HAS A LEGAL CONCERN?
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SELF
MY CHILD
HOW MANY CHILDREN?
I AM A CONCERNED (CHECK ALL THAT APPLY)
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VACCINE MANDATE
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SECTION B
VACCINE INJURY
ARE YOU OK? DO YOU NEED MEDICAL ATTENTION?
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WHICH VACCINE MANUFACTURER?
MODERNA
PFIZER
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REASON FOR VACCINATION?
EMPLOYER REQUEST
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Section C
School or Employer information. If personal choice, please skip to Section D
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NAME OF PERSON ENFORCING MANDATE
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SECTION D
LEGAL INQUIRY
ARE YOU INTERESTED IN FILING A LAWSUIT?
NO
YES
IF NO, DO YOU NEED MORE INFORMATION?
NO
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WHAT INFORMATION? (CHECK ALL THAT APPLY):
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MASK SCIENCE
VACCINE SCIENCE
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EMERGENCY USE AUTHORIZATIONS LAWS
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EMPLOYER MANDATE
SECTION A
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SELF
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HOW MANY CHILDREN?
I AM A CONCERNED (CHECK ALL THAT APPLY)
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PARENT
TEACHER
SCIENTIST
ADMINISTRATOR
HEALTH PRACTITIONER
GRANDPARENT
OTHER
WHAT IS YOUR CONCERN (CHECK ALL THAT APPLY)
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VACCINE MANDATE
MASK MANDATE
PCR TEST MANDATE
VACCINE INJURY
FULL LEGAL NAME
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Last
PHONE
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EMAIL
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ADDRESS
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Street Address
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HAVE YOU SPOKEN WITH OR HIRED A LAWYER BEFORE ON THIS ISSUE?
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SECTION B
EMPLOYER MANDATE
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VERBAL
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Maryland
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Legislation
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School Mandate
SECTION A
CONTACT INFORMATION / GENERAL INFORMATION
WHO HAS A LEGAL CONCERN?
*
SELF
MY CHILD
HOW MANY CHILDREN?
I AM A CONCERNED (CHECK ALL THAT APPLY)
Select All
PARENT
TEACHER
SCIENTIST
ADMINISTRATOR
HEALTH PRACTITIONER
GRANDPARENT
OTHER
WHAT IS YOUR CONCERN (CHECK ALL THAT APPLY)
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VACCINE MANDATE
MASK MANDATE
PCR TEST MANDATE
VACCINE INJURY
FULL LEGAL NAME
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First
Middle
Last
CONTACT PHONE
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PHONE
CONTACT EMAIL
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Address
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Street Address
Address Line 2
City
Alabama
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Arizona
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California
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Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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HAVE YOU SPOKEN WITH OR HIRED A LAWYER BEFORE ON THIS ISSUE?
*
NO
YES
SECTION B
SCHOOL MANDATE
HAS YOUR CHILD’S ATTENDANCE IN SCHOOL BEEN THREATENED IF YOU DO NOT COMPLY?
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YES
IF “YES” HAS THE THREAT BEEN
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VERBAL
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SCHOOL ADDRESS
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Tennessee
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