Vaccine Injury SECTION ACONTACT INFORMATION / GENERAL INFORMATIONWHO 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) Select All VACCINE MANDATE MASK MANDATE PCR TEST MANDATE VACCINE INJURY FULL LEGAL NAME* First Middle Last PHONE*EMAIL* ADDRESS* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code COUNTYHAVE YOU SPOKEN WITH OR HIRED A LAWYER BEFORE ON THIS ISSUE?* NO YES SECTION BVACCINE INJURYARE YOU OK? DO YOU NEED MEDICAL ATTENTION? NO YES WHICH VACCINE MANUFACTURER? MODERNA PFIZER J&J ASTRAZENECA OTHER PLEASE PROVIDE DATE OF JAB MM slash DD slash YYYY WHERE DID YOU RECEIVE THE JAB?ADDRESS OF JAB LOCATION Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code REASON FOR VACCINATION? EMPLOYER REQUEST EMPLOYER MANDATE SCHOOL REQUEST SCHOOL MANDATE PERSONAL CHOICE Section CSchool or Employer information. If personal choice, please skip to Section DWHO IS EMPLOYER OR SCHOOL?If school or employer, please continue. Otherwise, skip to section DPLEASE PROVIDE ADDRESS OF SCHOOL OR EMPLOYER Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NAME OF PERSON ENFORCING MANDATE First Last PHONEEMAIL SECTION DLEGAL INQUIRYARE YOU INTERESTED IN FILING A LAWSUIT? NO YES IF NO, DO YOU NEED MORE INFORMATION? NO YES WHAT INFORMATION? (CHECK ALL THAT APPLY): Select All MASK SCIENCE VACCINE SCIENCE PCR TEST SCIENCE EMERGENCY USE AUTHORIZATIONS LAWS CONSTITIONAL OR FEDERAL LAWS REGARDING MEDICAL CHOICE CONSTITIONAL OR FEDERAL LAWS REGARDING LOCKDOWN SCIENCE NameThis field is for validation purposes and should be left unchanged. Δ
