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Report of a vaccine side effect, vaccine reaction or a vaccine damage

For statistical evaluation of vaccine damages we request you to fill out the following form. The data will be published anonymously and handled with utmost confidentiality. If you wish, you have the option of withholding your name, date of birth and your address. The results help us to acquire accurate information about vaccine damages. Only the information marked with a black asterisk (*) will be published.

Please give the following information regarding the vaccinated person:

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Reported cases:
vaccindamage database

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