Vaccine Failure Reporting Form
Thank you for reporting your vaccine failure experience to NVIC. We take your experience and privacy concerns seriously. Personal identifying information you provide in this questionnaire will be kept confidential and used only as you direct us to use it. Sharing your story will help NVIC communicate and protect your human right to exercise voluntary, informed consent to vaccination.
You may choose to have your story posted publicly on NVIC’s Vaccine Failure Wall and/or allow us to use your story in our legislative efforts to protect vaccine freedom. Stories posted on our Vaccine Failure Wall will only contain the information you provide in the “YOUR STORY” box below along with a date stamp when the story was provided to us.
Required fields of information - The asterisk " * " indicates required fields of information.
Step 1 not completed
Step 2 not completed
Step 3 not completed
Step 4 not completed