Adverse Event Reporting Form

Adverse Event Reporting Form
Report vaccine harm here
Name
First NameLast Name
Birth Date
MonthDayYear
Email
example@example.com
Phone Number
Please enter a valid phone number.
State
Gender
FemaleMale
Blood type
A+A-B+B-AB+AN-O+O-
Select the vaccine brands you received
AstraZenecaJohnson&JohnsonBiontechModernaChinovaxPfizerSputnic VOther
How many COVID-19 vaccine doses did you receive?
Date of 1st Dose
MonthDayYear
Date of 2nd Dose
MonthDayYear
Date of 3rd Dose
MonthDayYear
Date of 4th Dose
MonthDayYear
Date of adverse reaction
MonthDayYear
Please select the symptoms and diagnosis
Allergic reactionAlopecia AreataAnaphylaxisAntibody-dependent Enhancement (ADE)AnxietyArythmiaBell's PalsyBladder control problemsBlood ClottingBlood Pressure ProblemsBody TremorsBone Density LossCancer - Return of Former SymptomsCancer - New SymptomsChronic Fatigue SyndromeCognitive DisabilityConfusionConstipationDepressionDiahorreaDysphagiaGuilain Barre SyndromeHaemorrhageHair lossHearing ProblemsHivesHyperhidrosisLoss of ConsciousnessLoss of ImmunityLow platelet issuesMenstrual ChangesMiscarriage or Still BirthMusculoskeletal DisordersMyocarditisPainPanic AttacksPericarditisPhysical DisabilityPneumoniaPostural orthostatic tachycardia syndrome (POTS)PriapismSexual DysfunctionShinglesSkin DiseaseSpion's DiseaseStrokeSuicide ideationToxic ShockTransverse MylitisVaginal UlcersVision problemsOther
What treatment did you receive?
HospitalisationIntensive Care UnitIntubationOutpatientHome careTime off workUnable to workNeed for permanent careApparent full recoveryCondition improvingDeathOther
Please describe offered/prescribed medication and treatment
Which were the official reporting of the adverse reaction?
Recorded as vaccine injuryAttributed to COVIDDescribed as "rare"Described as "common"InconclusiveOther
What were your motivations for being vaccinated?
Belief to scienceGovernment policyBusiness requirementEducational requirementPeer pressureAdvertisingCelebrity influenceProtect familyNeed of travelCommon goodOther
Which of the following statements have been told at site of vaccination?
Was told that vaccines are perfectly safeWas told that side effects will be brief and harmlessWas told that vaccines can cause harm but it is worth the riskReceived a product information documentWas told that the Government has indemnified vaccine manufacturers against all claims for the harm caused by their products.Was told the benefits and risks of the vaccineMedical staff checked medical historyWas given time to think about it and get a second opinionWas advised that there is a system for reporting online the adverse consequences of vaccination.
Attitude to COVID-19 vaccination
I would accept another vaccination or booster shot if instructed by the authoritiesI would not accept another vaccinationI will encourage friends to be vaccinatedI will discourage friends from being vaccinatedThe vaccination program should stop
Further questions and comments
Should be Empty: