National Vaccine
Information Center

Your Health. Your Family. Your Choice.
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Vaccine Failure Report

Vaccine Failure Graphic

Thank you for reporting your vaccine failure experience to the National Vaccine Information Center (NVIC). 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 NVIC to use it.

Sharing your story with others will help NVIC communicate important information about vaccination to the public and will help protect the human right to exercise voluntary, informed consent to vaccination.

No Vaccine is 100 percent effective or safe. Sometimes vaccines cause reactions and sometimes they fail to provide temporary or long-term protection against the infectious disease they are supposed to prevent.

Some attenuated live virus vaccines can cause vaccine strain viral infection in the vaccinated person or a close contact of that person. For example, live smallpox vaccine can cause vaccinia infection and use of live oral polio vaccine was discontinued in the U.S. in 1999 because it can cause vaccine strain polio. There are published reports of vaccine strain infections after live virus vaccines have been administrated to children and adults for measles, mumps, rubella, rotavirus, influenza, chickenpox (varicella zoster) and shingles (herpes zoster) vaccines.

If a live virus vaccine you or your child received did not protect against the infectious disease it was supposed to prevent OR it caused a vaccine strain infection, you can share your story with the general public and/or legislators by filling in the form below. You may choose to share your story in one or both of the following ways:
  • Publicly on NVIC.org on our Vaccine Failure Wall: The personal experience with vaccine failure or vaccine strain viral infection that you describe in the “YOUR STORY” box below will appear with a date stamp;
  • Share with Legislators to Protect Vaccine Choice: Sharing personal experiences with legislators is a powerful testimony for why it is necessary to protect the legal right to make  vaccine choices. You can give NVIC permission to share with legislators your experience described in the “YOUR STORY” box below along with your name and address.   (Legislators require contact information when confirming the validity of these reports. Your name and address will only be shared with legislators and will not be posted on NVIC.org)

Required Fields of Information – The red asterisk " * " indicates required fields of information. 

PERMISSION TO SHARE MY STORY

NVIC may publish my story on the Vaccine Failure Wall.*

NVIC may share my story, name and address in their legislative efforts to protect vaccine choices.*

CONTACT INFORMATION

First Name*
Zip/Postal Code*
Last Name*
Country*
Street*
Work Phone
 
City*
Home Phone*
 
State/Province*

If outside US, please specify province:
E-mail*
Which vaccine failed to prevent illness?
  Other, describe:
 What happened?
 
What year did the vaccine failure happen?*
UPLOAD YOUR PHOTO (Optional)

Upload:
You can upload .jpg, .gif, .bmp, .png, and .jpeg photos (100 KB file size or less).

YOUR STORY -
Please describe what happened in your own words below.*
 

INFECTION CONFIRMATION
Was the vaccine's failure to protect OR vaccine strain infection confirmed by a doctor or lab test?

If YES, do you have copies of the medical record confirming the vaccine failure OR vaccine strain infection?


EMPLOYMENT REQUIREMENTS
Were you forced as a condition of employment  to receive the vaccine that failed?

Did you have to purchase the vaccine that failed?

 

Thank you for taking the time to fill out our vaccine failure report!

  




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