National Vaccine
Information Center

Your Health. Your Family. Your Choice.
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NVIC Reaction Report Form

Mom and ChildThank you for reporting your vaccine reaction experience to NVIC's Vaccine Reaction Registry. We take your experience and privacy concerns seriously. Identifiable personal information you provide in this questionnaire will be kept confidential and used only as you direct us to use it.

Once you complete this report you will be taken to a webpage that contains many links to resources that may be helpful to you. Some of the resources you will have the opportunity to click through to view are the Federal Vaccine Adverse Event Reporting System (VAERS) and information regarding vaccine injury law and how to file a vaccine inury compensation claim.
 
Required fields of information - The red asterisk " * " indicates required fields of information.
 


CONTACT INFORMATION

Email Address:*
State/Province:*
Your Name:
Zip/Postal Code:*
Mailing Address:*
Country:
City:*

 
Phone:

 
REACTION INFORMATION  
Name of person who reacted:
Current Age:
Date of Birth:
Now
Date of Death:
Now
Date Vaccines Received:
Now
Primary Reaction:
Date Reaction Started:
Now
Current Health Problems:

Which Vaccine(s) - Check All That Apply:











































Reaction History:

Sick 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:
ADDITIONAL INFORMATION
How did you hear about NVIC?
Would you like to be in touch with others who have experienced vaccine reactions? 
Would you like to be contacted by phone or email?
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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