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Vaccine Reporting Systems

NVIC Reaction Registry Reporting Form

Protect Your Right to Informed Consent to Vaccination

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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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
E-mail is required
Country is required
Street address is required
City is required
State is required
Zip / Postal Code is required
Relationship to Person who Reacted is required
Reaction Information

Please provide the following reaction information.

At least one vaccine is required
Sick at vaccine time? *
Sick at vaccine time is required
On antibiotics or other drug medication? *
On medication is required
Family and Personal History

List any of the following: Neurological history, Autoimmune history, and/or Previous reaction history

Additional Information
Would you like to be in touch with others who have experienced vaccine reactions? *
If be in touch is required
Would you like to be contacted by phone or email? *
How contacted is required
Would you consider speaking publicly about your vaccine reaction experience? *
If consider speaking is required
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