Report A COVID-19 Vaccine Injury

Name (required)

Email (required)

Phone (required)

Zip Code (required)

Approximate Date Vaccine Received (required)

Vaccine(s) Received (required)

How long after vaccine did injury begin (required)

Description of the injury (required)

Date of birth (required)

Sex (male or female) (required)

Date and time of vaccination (required)

Date and time the adverse event (health problem) started (required)

Age at vaccination (required)

Whether the patient was pregnant at the time of vaccination and the due date (for females
only, if applicable) (required)

Prescriptions, over-the-counter medications, dietary supplements and herbal remedies
being taken (required)

Allergies to medications, food, or other products (required)

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