Vaccine Reporting Systems

Vaccine Failure Reporting Form

Protect Your Right to Informed Consent to Vaccination

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.

  1. Step 1 not completed
  2. Step 2 not completed
  3. Step 3 not completed
  4. Step 4 not completed
Permission to Share My Story
NVIC may publish my story on the Cry for Vaccine Freedom Wall
Response required
NVIC may share my story, name and address in their legislative efforts to protect vaccine choices
Response required
Contact Information

Please provide the following contact information.

First name is required
Last name is required
Street address is required
City is required
Zip / Postal Code is required
Country is required
E-mail is required
Home phone is required
Work phone is required
Vaccine Information

Please provide the following reaction information.

Which vaccine is required
A 4 digit failure year is required
Image Upload
You can upload .jpg, .gif, .bmp, .png, and .jpeg photos (100 KB file size or less).
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
Did you have to purchase the vaccine that failed?
Were you forced as a condition of employment to receive the vaccine that failed?
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