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Vaccine Reporting Systems

Vaccine Harassment Reporting Form

Protect Your Right to Informed Consent to Vaccination

Thank you for reporting your experience with vaccine harassment to NVIC. We take your experience and privacy concerns seriously. Identifiable personal 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 Cry for Vaccine Freedom Wall and/or allow us to use your story in our legislative efforts to protect vaccine freedom. Stories posted on our Cry for Vaccine Freedom 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.

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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
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.

DENIED CARE: Were you or your child denied medical care, or kicked out of a medical practice because of your vaccine decision?
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Rejected Vaccine Exemptions
Have you been rejected for a medical exemption to vaccination?
Have you been rejected for a religious exemption to vaccination?
Have you been rejected for a philosophical, personal or conscientious exemption to vaccination?
Please select the official(s) that rejected the vaccine exemption (please check all that apply)
Additional Information
FAMILY AND PERSONAL HISTORY: Do YOU, or your CHILD or your FAMILY have a history of (please check all that apply)
SPEAKING PUBLICLY: Would you like to speak publicly about being harassed about your beliefs about vaccination?
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