NVIC Reaction Registry Reporting Form
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. Information you share in the story section is made public. 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. NVIC encourages the public to also file a reaction report with VAERS to assist in the indentification of vaccine safety signals.
Required fields of information - The red asterisk " * " indicates required fields of information.
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