Vaccination Incident Report Form
Use this form to report any injustice or bad result involving vaccines in New Zealand. Important Note: This is NOT a medical report form and should only be used to report abuses in human rights, normal decency, or departure from healthy or decent treatment as a citizen. The information submitted here will be stored online on a private google account and due discretion is advised. We will treat all reports as confidential but offer no guarantee against hacking. For more personal reports it is suggested you contact us by e-mail.

http://citizensgovernmentcorruptionwatchdogcommission.yolasite.com/

Full Name
Your answer
E-Mail Address
Your answer
What type of vaccination?
Your answer
Please explain briefly the abuse suffered:
Your answer
Location
(Which city or town)
Your answer
Date of incident:
(When did this happen? If over a period, please state what dates this covered)
Your answer
Please list any adverse reactions as a result of vaccination given:
Your answer
If there is any other relevant information please let us know here. We may contact you for further questions if needed (at the email address supplied above).
Your answer
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