Option 4 - Current/Former Servicemember w/ Covid-19 Grievance
Please complete this intake form if you complied with the Military Covid-19 Vaccination Order and have grievances OTHER THAN A VACCINE INJURY as a result. 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 current or former member of the United States Military who complied with Covid-19 vaccination and would like to express a grievance? *
What is the zip code for your residence? (To identify your representative in Congress) *
What is/was your military branch? *
What is/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 is your current rank? (or your highest rank while in service if now separated) *
Did you voice any objections prior to complying with 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 the vaccine, did you understand that it was a 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?
Clear selection
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 vaccination, 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 had heard of any military whistleblowers, would you still have complied with the vaccination?
Clear selection
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 before vaccination? *
If yes, what was the outcome?
Clear selection
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)

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