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NVIC Reaction Report Form

Please use this form to report to the National Vaccine Information Center.  This information will be strictly confidential and will not be shared without your prior consent.  
*required


Email Address:*

Your Name:*

Mailing Address:*

City:*

State/Province:*

Zip/Postal Code:*

Country:*

Phone:

Name of person who reacted:

Date of Birth:
Now

Date of Death:
Now

Current Age:

Date Vaccines Received:
Now

Which Vaccine:








































Primary Reaction:

Date Reaction Started:
Now

Current Health Problems:

Reaction History:

Ill at time of vaccine?:

On antibiotics or other drug medication?:

FAMILY AND PERSONAL HISTORY: List any of the following: Neurological history, Autoimmune history, and/or Previous reaction history
Child (describe):

Relatives (describe):

Allergies before reaction:

Allergies after reaction:

How did you hear about NVIC?:

Would you like to be contacted by phone or email?:**

Would you like to be in touch with others who have experienced vaccine reactions?:

Would you consider speaking publicly about your vaccine reaction experience?:

Thank you for taking the time to complete this Vaccine Reaction Report to NVIC.


** By granting NVIC permission to follow-up on this report, NVIC will also email our free e-newsletter and send to you other educational outreach information.



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