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Vaccine Injury Reporting Form
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* Indicates required question
Email
*
Your email
Name of Injured Person
*
Your answer
Age
*
Your answer
Gender
*
Choose
Male
Female
Type of vaccine administered
*
Mention 1 or 2 shots and also company/brand of the vaccine
Your answer
Date Administered (1st shot)
*
MM
/
DD
/
YYYY
Date Administered (2nd shot)
MM
/
DD
/
YYYY
Place of vaccine administration
Your answer
Summary of Injury
*
Choose
Mild Event
Severe Event
Death
Description of injury
*
(please include description of health conditions prior to vaccination)
Your answer
Filled By
*
Your answer
Phone
*
Your answer
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