Fill out this form to report a vaccine adverse effect or injury. Your First Name *Your Last Name *Your Email Address *Your Nationality *Your Date Of Birth *2122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319220102030405060708091011120102030405060708091011121314151617181920212223242526272829303132Your Ethnicity *American IndianAsianAsian / FinnishBlackAfrican / Non-African BlackHispanicNative HawaiianWhiteOtherYour Gender *FemaleMaleDate Of Vaccination *Date Of Injury *Reason For Taking Vaccine VoluntaryEmployer MandateMilitary MandatePrison / Institution MandateFamily / Peer PressureOtherName / Location Of Facility Where Vaccine Was Administered *Which Vaccine Caused Injury? *COVID19 AstraZenecaCOVID19 JanssenCOVID19 ModeRNACOVID19 Pfizer-BioNTechHPV GardasilOtherIf Other, Specify Vaccine Injury Severity *Life ThreateningDisability, Permanent / SevereMedical Attention Was NeededMild Pain / DiscomfortVaccine Injury Type *Cardiac / Vascular DiseaseBirth Defect / CongenitalImmune ResponseNeurological SymptomsInjection Site Pain / DiscomfortReproductive IssuesStillbirth / MiscarriageOtherProvide Any Additional Information Here Would you like a copy of this report sent to the email address you provided? YesNoCommentSubmit