National Vaccine
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Vaccine Harassment Reporting Form

The personal identifiable information collected in this questionnaire will be kept confidential. The details of your experience will help NVIC to better represent the right of every individual to exercise informed consent over the vaccines administered to themselves or their children.

If you would like to have the NARRATIVE you write below posted publicly on the Cry for Vaccine Freedom Wall on this website, please indicate below by answering YES. All other information on this Vaccine Harrassment Reporting Form will be kept confidential.

CONTACT INFORMATION
Please provide the following contact information:
First Name*

Last Name*

Street Address*

Address (cont.)

City*

State/Province*

  If outside US, please specify state:

Zip/Postal Code*

Country*

Work Phone*

Home Phone*

E-mail*

 
VIEWS ON VACCINES:
Do you object to all vaccines or only specific ones? Please check all that apply:














 
Why do you object to one or more vaccines? Please check all that apply:


 
REJECTED VACCINE EXEMPTIONS:
Have you been rejected for a medical exemption to vaccination?

Have you been rejected for a religious exemption to vaccination?

Please select the official(s) that rejected the vaccine exemption (please check all that apply):






Please describe what happened in your own words in the box below. If you want what you describe in the box below to be publicly posted on the "Cry for Vaccine Freedom Wall" on this website, please check "YES" (personal identifying information will NOT be posted, only the narrative you write below). If you do NOT want what you describe in the box below to be posted on this website, please check NO.

YOUR NARRATIVE
UPLOAD YOUR PHOTO
Upload:
Please limit the size of your photo to 100 KB or less.

FAMILY AND PERSONAL HISTORY
Do YOU, or your CHILD or your FAMILY have a history of (please check all that apply):



Would you like to speak publicly about being harassed about your beliefs about vaccination?
Thank you for taking the time to fill out the above form.
 
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