AFLDS Kentucky Constituent Form
AFLDS is looking for Kentucky healthcare workers whose job wants to force them to take the Covid-19 vaccine. Please fill out this form (there are no “right” answers so please be accurate!!) if you are even THINKING about legal action! Even if you have chosen to be vaccinated, if you don’t want to live in a country where your employer can do such things, please fill out the form. If your information matches our criteria, our legal team will get in touch with you. You can share this link with other workers from your hospitals with vaccine mandates: https://americasfrontlinedoctors.org/kentucky/
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
If you have a “home” address that is in-state, please use that address.
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
County
*
Do you interact with patients? (Work in a clinical setting.)
*
Yes
No
Do you work remotely?
*
Yes
No
Are you a:
*
Please Select
Nurse
Doctor
Technician/Ancillary seeing patients (lab, XR, RT, PT etc.)
Maintenance (housekeeping, cafeteria, similar)
Admin or Support Staff or similar
Insurance/Billing/Coding/Similar
Have you already submitted an exemption request to your job?
*
Yes
No
Other
Have you ever had Covid-19?
*
Yes
No
Evidence of prior Covid-19?
*
PCR Test
Antibody Test
Symptoms
N/A
Have you or a family member ever had a bad reaction to a vaccine in the past?
Yes
No
Please explain:
Do you have a health issue which you feel puts you at risk for taking the Covid vaccine?
Yes
No
Please explain:
I’ve taken the Covid Vaccine and am experiencing adverse reactions or events?
Yes
No
Please explain:
You understand that you are submitting personal information related to your health. Your data will NEVER be shared, sold or rented.
*
I Understand
Submit
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