Covid 19 Vaccine Class Action

Covid 19 Vaccine Class Action

Group Member Details
Registration of details for group member- Covid Vaccine Class Action

PLEASE NOTE: This form will NOT save your response automatically. We recommend that you type any substantive responses in a Word Document in the first instance and then copy and paste same into the below form. Additionally, if you start filling out the form and wish to finish the form at a later time, please ensure that you save all of your substantive responses in a separate document (e.g. word document).
Name of Covid-19 Vaccine Injured Party*

First NameLast Name
Date of birth*

DayMonthYear
Date
Are you completing this form for yourself, or someone else; and if so please state the basis of same.*

I am completing this form about my vaccine reactionI am completing this form on behalf of another person
If completing this form on behalf of another person, what is your name?

First NameLast Name
If completing this form on behalf of another person, please state the basis of same.
Contact email for the person completing this form*
example@example.com
Address for the person completing this form

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best contact number for the person completing this form*

Area CodePhone Number
Today's Date

DayMonthYear
Date
The information you provide will be for the purpose of consenting to be a group member of the Covid Vaccine Class Action, and will be collected, used and shared only for this purpose and only with the members of the legal team and the court, and in accordance with Australian Privacy Principles. Please complete this information only if there has been an adverse event or complication from the vaccine/s. Do you consent to the collection of this information and to be a class member for this action, and did you either have a reaction to a Covid 19 vaccine or have a family member die after their Covid 19 vaccine?*

YesNo
If known, please select the first Covid 19 vaccine received*
Details about your first Covid 19 Vaccine
What was the date of the first Covid 19 vaccine received? If you do not know exact date, please pick the 1st day of the month and year as close as you know. *

DayMonthYear
Date
Was there any serious reaction after the first Covid-19 vaccine? Serious just means more than a fever, minor reaction or sore arm. This might mean something you needed to see a doctor for, or go to hospital about, or have tests for and anything that caused more long term health effects.

YesNo
If you had serious reaction from the first vaccine, please provide a summary of what happened to you after the first vaccine. For example, what symptoms you noticed and how soon after the vaccine you noticed them. If you saw any doctors or went to hospital or a description of what happened next. Please make a summary of any tests you had after that, and any treatments. Please make a summary of what symptoms or impacts you still have since this first vaccine.
Are you completing this form for a family member who died after their first vaccine?

YesNo
If yes, what was the date of death?

DayMonthYear
Date
Details about your Second Covid 19 Vaccine
If known and if applicable, please select the second Covid 19 vaccine you received*
What was the date of the second Covid 19 vaccine you received? If you do not know exact date, please pick the 1st day of the month and year you recall you had the first vaccine.

DayMonthYear
Date
If you had a second vaccine, did you have any serious reaction after your second Covid-19 vaccine? Serious just means more than a fever, minor reaction or sore arm. This might mean something you needed to see a doctor for, or go to hospital about, or have tests for and anything that caused more long term health effects.

YesNoI did not have a second
If you had any serious reaction from the second vaccine, please provide a summary of what happened to you after the second vaccine. For example, what symptoms you noticed and how soon after the vaccine you noticed them. If you saw any doctors or went to hospital or a description of what happened next. Please make a summary of any tests you had after that, and any treatments. Please make a summary of what symptoms or impacts you still have since this vaccine.
Are you completing this form for a family member who died after their second vaccine?

YesNo
If yes, what was the date of death?

DayMonthYear
Date
Details about your Third Covid 19 Vaccine
If known and if applicable, please select the third Covid 19 vaccine you received*
What was the date of the third Covid 19 vaccine you received? If you do not know exact date, please pick the 1st day of the month and year you recall you had the first vaccine.

DayMonthYear
Date
If you had a third vaccine, did you have any serious reaction after your third Covid-19 vaccine? Serious just means more than a fever, minor reaction or sore arm. This might mean something you needed to see a doctor for, or go to hospital about, or have tests for and anything that caused more long term health effects.

YesNoI did not have a third vaccine
If you had any serious reaction from the third vaccine, please provide a summary of what happened to you after the third vaccine. For example, what symptoms you noticed and how soon after the vaccine you noticed them. If you saw any doctors or went to hospital or a description of what happened next. Please make a summary of any tests you had after that, and any treatments. Please make a summary of what symptoms or impacts you still have since this vaccine.
Are you completing this form for a family member who died after their third vaccine?

YesNo
If yes, what was the date of death?

DayMonthYear
Date
Details about your Fourth Covid 19 Vaccine
If known and if applicable, please select the fourth Covid 19 vaccine you received*
What was the date of the fourth Covid 19 vaccine you received? If you do not know exact date, please pick the 1st day of the month and year you recall you had the first vaccine.

DayMonthYear
Date
If you had a fourth vaccine, did you have any serious reaction after your fourth Covid-19 vaccine? Serious just means more than a fever, minor reaction or sore arm. This might mean something you needed to see a doctor for, or go to hospital about, or have tests for and anything that caused more long term health effects.

YesNoI did not have a fourth vaccine
If you had any serious reaction from the fourth vaccine, please provide a summary of what happened to you after the third vaccine. For example, what symptoms you noticed and how soon after the vaccine you noticed them. If you saw any doctors or went to hospital or a description of what happened next. Please make a summary of any tests you had after that, and any treatments. Please make a summary of what symptoms or impacts you still have since this vaccine.
Are you completing this form for a family member who died after their fourth vaccine?

YesNo
If yes, what was the date of death?

DayMonthYear
Date
Covid-19 Infection(s)
Have you had confirmed Covid 19 infection?

YesNo
If Yes to having confirmed Covid 19 infection, please select below the best description of how your Covid 19 infection related to your vaccine reaction (Do not worry if you had Covid more than once, please pick the best description to tell us if having Covid made any impact on the adverse event after your vaccine).

I had Covid before the vaccine, and had no ongoing issues from Covid at the time I took the vaccineI had Covid before the vaccine, and I had ongoing symptoms from Covid that were still present at the time I had my vaccineI had Covid after my vaccine reaction, and it did not make a difference to the vaccine reaction.I had Covid after my vaccine reaction, and it made the adverse reaction worse or increased the adverse event in some way.Other
Please include any important information you would like to add about any Covid infection in relation to your adverse reaction
Australian Government Covid-19 Vaccine Claims Scheme
Have you attempted to make a claim under the Australian Government's Covid-19 Vaccine Claims Scheme?

YesNo
If you have attempted to make a claim under the Australian Government's Covid-19 Vaccine Claims Scheme, please state the result of same and briefly describe your experience with the Vaccine Claims Scheme.
General Information
Please provide a summary of your general health before any Covid 19 vaccine reaction. For example, you might tell us if you were working or studying, what your level of physical fitness and activity was, what hobbies you enjoyed, what your social and family situation was. If completing for deceased person, please tell us a little about their health and life before the vaccine.
Please summarise how your life has changed since the reaction to the vaccine. For example, you might tell us about if you are not able to work, study or care for your children. You might tell us about this has impacted your career, relationships, daily functions and enjoyment of life. If completing for a deceased person, please tell us about any one who was dependant on the deceased person for income and also about the impacts on the family members since the death.
Please tell us about any ongoing medical complications from the vaccine. For example, if you are now on any regular medications, or if you need to have regular doctors visits, or if you have been told that you need to have more tests or treatments.
Is there anything else you would like to say?
Please upload any medical files, doctors letters or confirmation of vaccination records- note 600KB file size limit, please use PDF where possible and limit large files. Once enrolled as Group Member, if required you will be able to provide further medical evidence and records

Cancelof
Date*

DayMonthYear
Date
Name*

First NameLast Name
Your Signature*
Should be Empty:

Covid 19 Vaccine Class Action

Registration of details for group member- Covid Vaccine Class Action

Details about your first Covid 19 Vaccine

Details about your Second Covid 19 Vaccine

Details about your Third Covid 19 Vaccine

Details about your Fourth Covid 19 Vaccine

Covid-19 Infection(s)

Australian Government Covid-19 Vaccine Claims Scheme

General Information