Report of a vaccine side effect, vaccine reaction or a vaccine damage

For statistical evaluation of vaccine damages we request you to fill out the following form. The data will be published anonymously and handled with utmost confidentiality. If you wish, you have the option of withholding your name, date of birth and your address. The results help us to acquire accurate information about vaccine damages. Only the information marked with a black asterisk (*) will be published.

Please give the following information regarding the vaccinated person:

Date of today:

Name of the vaccinated person:

First name of the vaccinated person:

Date of birth of the vaccinated person(yyyy-mm-dd):

Gender:* female male

Country:*

Name of the notifying person:

Address:

ZIP/Postal Code:

City:

State/Province/Region:

Telephone:

Email:*

Were you or your child healthy before the vaccination? Yes No

If not, what illness did you have?*

Which vaccination was administered?*

Was a second vaccination administered at the same time?*

Was a third vaccination administered at the same time?*

Was a fourth vaccination administered at the same time?*

Was a fifth vaccination administered at the same time?*

Exact name(s) and manufacturer of vaccine:*

Date of vaccination(yyyy-mm-dd):

Age group when vaccinated:*

Exact age when vaccinated:

Describe the exact vaccine reactions and what you observed (as detailed as possible, not just notes):**

Hospitalized? ER? Yes No

Time period between the vaccine and the occurrence of the first symptoms:

Outcome of the vaccine reaction:*

Is there any permanent damage? (If yes, what?):*

Where did you hear about www.vaccineinjury.info(website)?

Reported cases:

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Report of a vaccine side effect, vaccine reaction or a vaccine damage

Summary of you vaccine damage report:

Thank you very much for your report!

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