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Reporting Vaccine and Vaccine Registry Harassment, Discrimination and Coercion Incidents

Please fill out one form per incident. Thank you.

Category of Harassment, Discrimination, or Coercion







Specify:

 

Incident Details:
    Date
    Name of Entity
    Name of Individual(s)
    City
    State
    Zip Code

Fully Describe What Happened

Consequence or Harm
Examples: vaccine injury, doctor threw you out, dumped from or harassed by insurance, child protective services, emotional distress, etc.)

Has this Experience Affected Your Views on Immunization?
(Please explain...)

Permission

I understand that by my filling out this form, only the above information will be shared with legislators or on the PROVE website to help bring attention to these problems. I also understand that my personal contact information below will be kept in confidence and will only be used by PROVE so that we may communicate with you about your experience, if necessary. If we receive a request from a legislator or anyone else inquiring about your personal situation, we will forward that inquiry to you personally so that you and you alone can decide if you would like to communicate with them.

Confidential Contact Information:

    Name

    Email

    Address

    City

    State

    Zip code

    Country

    Work Phone

    Home Phone

Please enter confirmation code displayed in the image below:

Confirmation Code
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October 10, 2010

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