WORLD COVID VACCINE HARM REPORT

REPORT VACCINE HARM HERE. Receive a free link to UNCHAIN AUSTRALIA: Policies for Peace, Progress and Prosperity. The only mandatory field is your email address. Information is confidential unless the individual concerned expressly authorises publication. You will receive confirmation in an email which you can forward to your doctor, to media, to your politician, and to your group of caring friends.
Name of person who took vaccine and suffered harm
A first name is sufficient, full name if you wish
Share this nameKeep this name confidential
Name for sharing
If blank, the name will not be disclosed
MaleFemale
AustraliaCanadaIndiaIndonesiaPNGEuropeIrelandNew ZealandUKUSAOther
NiuginiPapuaBougainville
ACTNSWQldNTSATasVicWA
ABNSBCNUMBONNBPEQCNLNSSKYT
APARASBRCTGAHRHPJHKAKLMPMHMNMLMZNLORPBRJSKTNTGTNTGTRULUPWBANCHDNDDDLJKLALDPY
ALADAMATBEBGBYBACYCZDEESFOGEGIISIMSPFIFRGRHRHUIEITXKLILTLULVMAMKMDMCMENLNOPOPTRORUSMRSSESISKCHTRUAVA
North IslandSouth Island
Channel IslandsEnglandNorthern IrelandScotlandWales
ALAKAZASCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNEMVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
I am the individual described hereI am describing a member of my familyI am describing another person
If you are describing another living person, that individual's identity and personal details will be kept confidential, unless you provide those details in the narrative section.
Name of person filling this form if not the victim
First name is sufficient. Up to you.
Year of birth of vaccine recipient
If unsure, please make your best guess
Date of first vax injection
If unsure, please make your best guess
Date of second vax injection
If unsure, please make your best guess
Date of third vax injection
If unsure, please make your best guess
Date of hospitalisation if applicable
If unsure, please make your best guess
AstraZenecaChinovaxJohnson&JohnsonModernaNovavaxPfizerSinopoharmSputnik VThey did not tell meOther
AstraZenecaChinovaxJohnson&JohnsonModernaNovavaxPfizerSinopharmSputnik VOther
Government said soTeacher said soPeer pressureThe boss insistedAdvertisingProtect my familyCelebrity influenceEducation requirementThe coach insistedNeed to travelCommon goodOther
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 [in Australia to the Therapeutic Goods Administration (TGA)] the adverse consequences of vaccination.Other
Date of adverse reaction
If unsure, please make your best guess
To personal doctorTo a hospitalTo ambulanceTo employerTo TGAUnreportedOther
If your adverse event was not reported to the TGA, we recommend that after submitting this form you make a report at https://aems.tga.gov.au
By personal doctorBy specialistBy hospital doctorOther
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
HospitalisationIntensive Care UnitIntubationOutpatientHome careTime off workUnable to workNeed for permanent careApparent full recoveryCondition improvingDeathOther
Tests, Treatment or Medication, offered or prescribed
Kind and helpfulListened and caredDenied vaccine harmDismissiveHostileOther
A Post-Mortem was conductedThere was no Post MortemA Post Mortem was requested but refusedA Death Certificate was issuedDeath was reported to TGATGA confirmed death was vaccine-causedOther
Recorded as vaccine injuryAttributed to COVIDDescribed as "rare"Described as "common"InconclusiveOther
Narrative: Please write as much as you wish. Whatever you write will be taken seriously and included in correspondence with the authorities. Please do not write in this narrative section any information (for example a name) which you wish to keep confidential.
A+A-B+B-AB+AN-O+O-Other
Willing to be interviewed by telephoneWilling to be interviewed in personWilling to appear on televisionWilling to be quoted in a book, newspaper or magazineWilling to be photographed by mediaPrefer not to be interviewedWilling to be contacted by other victimsOther
Willing to be interviewed with a view to giving evidence in a potential criminal prosecution.
Compensation is neededAlready taking actionWilling to consider joining a class actionOther
Helpful politician(s) whom you have approached
Unhelpful politician(s) whom you have approached
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
email (required field)*
Share my email with other victims, supporters and the mediaUse my email address only for verification and communicating with me
email for sharing
.
email not for sharing
Profession or occupation
Person making this report
Address (will be disclosed only to the Department of Health)
Including your address may assist to confirm your authenticity and possibly assist in obtaining redress. The decision is yours.
Postcode or Zipcode (will be disclosed)
Phone
Share my phone with other victims, supporters and the mediaUse my phone only for contacting me by voice or SMS
Phone for sharing
If blank your phone number will not be shared
I am today making a deposit of A$5 or more to Unchain Australia Trust, Great Southern Bank, BSB 814 282, account number 512 17432, and recording my name with the deposit. Please email to me with the acknowledgment of this form a FREE link to a pdf of UNCHAIN AUSTRALIA; Politics for Peace, Progress and Prosperity.
Please include a photo if relevant (optional)
WHAT THE SUBMIT BUTTON DOES

1. Generates an email to you, confirming the information you have provided. Attached to the email is a summary of the reports submitted by other victims of vaccine harm.

2. Writes your information to a secure database. This database is the evidence for representations to governments seeking compassion and compensation for victims of vaccines.

3. Takes you to the Facebook Group VAXHARM Victims of Vaccines Support Group, where, if you wish, you can repeat your story. Before you hit the Submit button, you may care to copy what you have written in the Narrative box, so you can paste your story directly into the Group page.

4. At the VAXHARM Victims of Vaccines Support Group page, you can access the latest update of a Digest of Vaccine Harm Reports which have been submitted through this site.
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