Nonself-Report

Patient-advocates may use this form to file a vaccine injury report on behalf of someone else who experienced an adverse reaction to a vaccine.

Your First Name *

Your Last Name *

Your Email Address *

Your Relationship With Patient

Patient First Name *

Patient Last Name *

Patient Nationality *

Patient Date Of Birth *

Patient Ethnicity *

Patient Gender *

Date Of Vaccination *

Date Of Injury *

Reason For Taking Vaccine

Name / Location Of Facility Where Vaccine Was Administered *

Which Vaccine Caused Injury? *

If Other, Specify

Vaccine Injury Severity *

Vaccine Injury Type *

Provide Any Additional Information Here

Would you like a copy of this report sent to the email address you provided?

Name