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.
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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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** 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.
