Self-Report

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 *

Your Ethnicity *

Your 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?

Phone