Please use this form to report to the National Vaccine Information Center.
*required
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| Email Address:* |
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| Your Name:* |
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| Mailing Address:* |
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| City:* |
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| State/Province:* |
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| Zip/Postal Code:* |
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| Country:* |
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| Phone: |
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| Name of person who reacted: |
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| Date of Birth: |
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| Date of Death: |
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| Current Age: |
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| Date Vaccines Received: |
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| Which Vaccine: |
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| Primary Reaction: |
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| Date Reaction Started: |
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| Current Health Problems: |
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| Reaction History: |
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| Ill at time of vaccine?: |
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| On antibiotics or other drug medication?: |
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| FAMILY AND PERSONAL HISTORY: List any of the following: Neurological history, Autoimmune history, and/or Previous reaction history |
| Child (describe): |
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| Relatives (describe): |
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| Allergies before reaction: |
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| Allergies after reaction: |
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| How did you hear about NVIC?: |
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| Would you like to be contacted by phone or email?: |
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| Would you like to be in touch with others who have experienced vaccine reactions?: |
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| Would you consider speaking publicly about your vaccine reaction experience?: |
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| Thank you for taking the time to complete this Vaccine Reaction Report to NVIC. |
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The information contained on this website is for educational purposes. While we strive to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the website or the information, products, services, or graphics contained on the website for any purpose. Any reliance you place on such information is therefore strictly at your own risk.
In no event will the National Vaccine Information Center, or any participant, contributor, endorser, or other associate of any kind thereof, be liable for any loss or damage, including, without limitation, indirect or consequential loss or damage, or any loss or damage whatsoever from any activities arising out of or in connection with the use of this website.
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