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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:
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