Date of today: Calendar

Name of the vaccinated person:

First name of the vaccinated person:

Date of birth of the vaccinated person(yyyy-mm-dd): Calendar

Gender:* female male

Country:* United States(USA) Canada United Kingdom Australia New Zealand --- Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Espana Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Republic of Korea (South) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Ireland Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Russian Federation Rwanda Saint Barthelemy Saint Kitts and Nevis Saint Lucia Saint Martin Saint Vincent and the Grenadines Samoa (Independent) San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka St. Helena St. Pierre and Miquelon Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States(USA) United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wales Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe

Name of the notifying person:

Address:

ZIP/Postal Code:

City:

State/Province/Region:

Telephone:

Email: *

Were you or your child healthy before the vaccination? Yes No

If not, what illness did you have?*

Which vaccination was administered?* - Anthrax BCG Diphtheria, Tetanus Diphtheria, Tetanus, Polio Diphtheria,Tetanus, Pertussis Diphtheria,Tetanus, Pertussis, HiB Diphtheria,Tetanus, Pertussis , Poliovirus Diphtheria, Tetanus , Pertussis, Poliovirus and Haemophilus b Diphtheria, Tetanus , Pertussis, Poliovirus, Haemophilus b, Hepatitis B Haemophilus b Haemophilus b & Hepatitis B Hepatitis A Hepatitis A + B Hepatitis B Human Papillomavirus, HPV Influenza Influenza, H1N1 Japanese Encephalitis Measles Measles, Mumps Measles, Mumps, and Rubella Measles, Mumps, Rubella and Varicella Meningococcal Vaccine Mumps Plague Pneumococcal Vaccine Poliovirus Rabies Rotavirus Rubella Smallpox TBE Tetanus Typhoid Varicella (Chickenpox) Yellow Fever Zoster(Shingles) Vaccine other

Was a second vaccination administered at the same time?* Anthrax BCG(Tuberculosis) Diphtheria, Tetanus Diphtheria, Tetanus, Polio Diphtheria,Tetanus, Pertussis Diphtheria,Tetanus, Pertussis, HiB Diphtheria,Tetanus, Pertussis , Poliovirus Diphtheria, Tetanus , Pertussis, Poliovirus and Haemophilus b Diphtheria, Tetanus , Pertussis, Poliovirus, Haemophilus b, Hepatitis B Haemophilus b Haemophilus b & Hepatitis B Hepatitis A Hepatitis A + B Hepatitis B Human Papillomavirus Influenza Influenza, H1N1 Japanese Encephalitis Measles Measles, Mumps Measles, Mumps, and Rubella Measles, Mumps, Rubella and Varicella Meningococcal Vaccine Mumps Plague Pneumococcal Vaccine Poliovirus Rabies Rotavirus Rubella Smallpox TBE Tetanus Typhoid Varicella (Chickenpox) Yellow Fever Zoster(Shingles) Vaccine

Was a third vaccination administered at the same time?* Anthrax BCG Diphtheria, Tetanus Diphtheria, Tetanus, Polio Diphtheria,Tetanus, Pertussis Diphtheria,Tetanus, Pertussis, HiB Diphtheria,Tetanus, Pertussis , Poliovirus Diphtheria, Tetanus , Pertussis, Poliovirus and Haemophilus b Diphtheria, Tetanus , Pertussis, Poliovirus, Haemophilus b, Hepatitis B Haemophilus b Haemophilus b & Hepatitis B Hepatitis A Hepatitis A + B Hepatitis B Human Papillomavirus, HPV Influenza Influenza, H1N1 Japanese Encephalitis Measles Measles, Mumps Measles, Mumps, and Rubella Measles, Mumps, Rubella and Varicella Meningococcal Vaccine Mumps Plague Pneumococcal Vaccine Poliovirus Rabies Rotavirus Rubella Smallpox TBE Tetanus Typhoid Varicella (Chickenpox) Yellow Fever Zoster(Shingles) Vaccine other

Was a fourth vaccination administered at the same time?* Anthrax BCG(Tuberculosis) Diphtheria, Tetanus Diphtheria, Tetanus, Polio Diphtheria,Tetanus, Pertussis Diphtheria,Tetanus, Pertussis, HiB Diphtheria,Tetanus, Pertussis , Poliovirus Diphtheria, Tetanus , Pertussis, Poliovirus and Haemophilus b Diphtheria, Tetanus , Pertussis, Poliovirus, Haemophilus b, Hepatitis B Haemophilus b Haemophilus b & Hepatitis B Hepatitis A Hepatitis A + B Hepatitis B Human Papillomavirus Influenza Influenza, H1N1 Japanese Encephalitis Measles Measles, Mumps Measles, Mumps, and Rubella Measles, Mumps, Rubella and Varicella Meningococcal Vaccine Mumps Plague Pneumococcal Vaccine Poliovirus Rabies Rotavirus Rubella Smallpox TBE Tetanus Typhoid Varicella (Chickenpox) Yellow Fever Zoster(Shingles) Vaccine

Was a fifth vaccination administered at the same time?* Anthrax BCG(Tuberculosis) Diphtheria, Tetanus Diphtheria, Tetanus, Polio Diphtheria,Tetanus, Pertussis Diphtheria,Tetanus, Pertussis, HiB Diphtheria,Tetanus, Pertussis , Poliovirus Diphtheria, Tetanus , Pertussis, Poliovirus and Haemophilus b Diphtheria, Tetanus , Pertussis, Poliovirus, Haemophilus b, Hepatitis B Haemophilus b Haemophilus b & Hepatitis B Hepatitis A Hepatitis A + B Hepatitis B Human Papillomavirus Influenza Influenza, H1N1 Japanese Encephalitis Measles Measles, Mumps Measles, Mumps, and Rubella Measles, Mumps, Rubella and Varicella Meningococcal Vaccine Mumps Plague Pneumococcal Vaccine Poliovirus Rabies Rotavirus Rubella Smallpox TBE Tetanus Typhoid Varicella (Chickenpox) Yellow Fever Zoster(Shingles) Vaccine

Exact name(s) and manufacturer of vaccine:*

Date of vaccination(yyyy-mm-dd): Calendar

Age group when vaccinated:* 0-1 Months 2-3 Months 3-4 Months 5-6 Months 7-12 Months 1-2 Years 3-4 Years 5-6 Years 7-12 Years 13-18 Years 19-29 Years 30-39 Years 40-49 Years 50-59 Years 60-69 Years 70-79 Years 80-89 Years >90 Years

Exact age when vaccinated: 0-1 week 2 weeks 3 weeks 4 weeks 5 weeks 6 weeks 7 weeks 8 weeks 9 weeks 10 weeks 11 weeks 12 weeks 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months 13 months 14 months 15 months 16 months 17 months 18 months 19 months 20 months 21 months 22 months 23 months 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years 29 years 30 years 31 years 32 years 33 years 34 years 35 years 36 years 37 years 38 years 39 years 40 years 41 years 42 years 43 years 44 years 45 years 46 years 47 years 48 years 49 years 50 years 51 years 52 years 53 years 54 years 55 years 56 years 57 years 58 years 59 years 60 years 61 years 62 years 63 years 64 years 65 years 66 years 67 years 68 years 69 years 70 years 71 years 72 years 73 years 74 years 75 years 76 years 77 years 78 years 79 years 80 years 81 years 82 years 83 years 84 years 85 years 86 years 87 years 88 years 89 years 90 years 91 years 92 years 93 years 94 years 95 years 96 years 97 years 98 years 99 years 100 years

Describe the exact vaccine reactions and what you observed (as detailed as possible, not just notes):* *

Hospitalized? ER? Yes No

Time period between the vaccine and the occurrence of the first symptoms: 0-6 hours 7-12 hours 13-24 hours 25-48 hours 3-4 days 5-7 days 8-14 days 15-21 days 22-28 days 5-8 weeks 3-4 months 5-6 months 7-9 months 10-12 months 1-2 years 3-5 years >5 years

Outcome of the vaccine reaction:* not yet recovered recovered permanent damage unknown death

Is there any permanent damage? (If yes, what?):*

Where did you hear about www.vaccineinjury.info(website)?

next

Summary of you vaccine damage report:

The information marked with an asterisk (*) will be published.

Date of today:

Name:

First name:

Date of birth:

Gender:*

Country:*

Name of the notifying person:

Address:

City and zip code

Telephone:

Email:

Previous illnesses:*

1. Vaccination:*

2. Vaccination:*

3. Vaccination:*

4. Vaccination:*

5. Vaccination:*

Exact name(s) and manufacturer of vaccine:*

Date of vaccination:

Age when vaccinated:*

Vaccine reaction:*

Hospital admission:

Time period between the vaccine and the occurrence of the first symptoms:

Permanent damage:*

Outcome of the vaccine reaction:*

Submit

Thank you very much for your report!