Option 2 - Covid-19 Forced Retirement/Voluntary Separation Service Member
Please complete this intake form if you did not comply with the Military Covid-19 Vaccination Order and were separated as a result. This form is not for involuntarily discharged soldiers as they have been offered a return to duty. For other intake form options please visit: www.militaryvaccineaccountability.org

**NOTE**
DO NOT provide any classified, personal, or otherwise private information that you do not wish to become open source. The information you provide will be used to generate a report that will be submitted to U.S. Congress, SECDEF, and their staffs. The information provided here will not be released publicly without your written permission.
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Please Confirm: Are you a former member of the United States Military who did not comply with Covid-19 vaccination and were forced into retirement/voluntary separation as a result? *
What is the zip code for your residence? (To identify your representative in Congress) *
What was your military branch? *
What was your component? *
What is your last name? *
What is your first name and middle initial? (Format: John, D) *
What is your DOD ID number? (Optional, will help streamline identification)
What is/was your commission classification? *
What was your highest rank? *
Did you voice any objections prior to receiving the vaccination order? *
Were you told that the vaccine was "safe and effective"? *
Were you told that the vaccine was FDA approved? *
At the time you received vaccination order, did you understand that it was an Emergency Use Authorization, and not FDA approved? *
Did you receive any kind of briefing or education about "informed consent" prior to being ordered to take the vaccine? *
Did any members of your chain-of-command or supervisors attempt to use coercion, guilt, or other inappropriate tactics during the vaccination order process? *
If yes, you may name them and describe what happened here, if desired.
Prior to the vaccination order, were you aware of any Covid-19 Vaccine whistleblowers? (e.g. LTC Theresa Long, LTC Peter Chambers, CDR Robert Green, LTC Carolyn Rocco)

If yes, please list their names here:
If you did hear about whistleblowers, did it impact your decision not to comply with the vaccination? *
Did you attempt to seek legal counsel from JAG? *
If yes, were they able to resolve your legal concerns? *
Did you submit an accommodation request? *
If yes, what was the outcome? *
Please share any other information as desired.
Do you request to be contacted by your Congressman/woman? *
Do you consent to be contacted by representatives of this project: Military Vaccine Accountability? *
What is your phone number? (optional)
What is your email address? (optional)
What is your physical mailing address? (optional)
Thank you for your dedicated service to our country and your participation in this survey.

Sincerely,

Military Vaccine Accountability
X, Instagram, Truth Social: @milvaxacct

Founders: 
CW2 Searcy (UTARNG)
CW2 Cadet (NDARNG)

"Give two disgruntled Warrant Officers google forms access and they will change the world." 
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