National Vaccine Information Center
Your Health. Your Family. Your Choice.
Thank you for reporting your vaccine reaction experience to NVIC's Vaccine Reaction Registry. We take your experience and privacy concerns seriously. Your name or your child’s name that you provide in this questionnaire will be kept confidential. By filling out this reaction report, you give NVIC permission to share your experience and demographic information for educational and legislative purposes.
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
REACTION INFORMATION
Which Vaccine(s) - Check All That Apply: Anthrax (AVA) (U.S. military personnel) Anthrax (Biothrax) (U.S. military personnel, first responders) BCG (Tuberculosis) Not recommended in U.S. COVID-19 (Trial Volunteers - Experimental) COVID-19 - Emergency Use (general populace) Diphtheria & Tetanus Toxoids (DT) Diphtheria, Pertussis, Tetanus (DPT/DTP - Not in use in US) DTaP (Acellular DTP)(Daptacel, Infanrix) DTaP, Hepatitis B (HepB), Inactivated Poliovirus (IPV) (Pediarix) DTaP, Haemophilus influenzae type b (Hib), IPV (Pentacel) DTaP-IVP (Kinrix, Quadracel) Hib PRP-T (ActHib, Hiberix) Hib PRP-OMP (PedvaxHIB) Hib-HepB (COMVAX) Hepatitis (HepA) (Havrix, Vaqta) HepA-HepB (Twinrix) HepB (Energix-B, HEPLISAV-B,Recombivax HB) Human Papillomavirus (HPV, Gardasil, Cervarix) Influenza – (Inactivated Trivalent and Quadrivalent) Influenza – Live nasal (FluMist) Influenza 2009 Pandemic H1N1 Japanese Encephalitis (JE-VAX, Ixiaro - travel vaccine) Measles (Attenuvax) – Not in use in U.S. Measles, Mumps, Rubella (M-M-R II) Measles, Mumps, Rubella, Varicella (MMRV) (ProQuad) Meningococcal ACWY (Menactra, Menveo, Menomune, MenQuadfi) Meningococcal B (MenB) (Bexsero, Trumenba) Mumps (Mumpsvax) Plague (U.S. military personnel) Pneumococcal, Polyvalent (Pneumovax-23) Pneumococcal, (Prevnar) Poliovirus – live oral (OPV) Poliovirus – inactivated (IPV) Rabies Rotavirus (ROTARIX) Rotavirus – pentavalent (RotaTeq) Rubella (Meruvax) Shingles/Zoster (Zostavax, SHINGRIX) Smallpox (U.S. military personnel) Tetanus, Diphtheria (Td - Adult) Tetanus Toxoid Tetanus, Diphtheria and Acellular Pertussis (Tdap) Typhoid (travel, U.S. military personnel) Varicella (Varivax) Yellow Fever (U.S. military personnel) Other (please specify)
Your Story - What Happened:
Sick at time of vaccine? YesNo
On antibiotics or other drug medication? YesNo
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? YesNo
Would you like to be contacted by phone or email? phoneemailPlease do not contact
Would you consider speaking publicly about your vaccine reaction experience? YesNoUnsure
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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