Reporting Vaccination Harassment, Discrimination and Coercion Incidents

Site
Web

You are here: >

Reporting Vaccination Harassment, Discrimination and Coercion Incidents

Please fill out one form per incident. Thank you.

Incident Details

Incident Date:*

Calendar

Offending Entity:*

Offending Individual(s):*

Incident City:*

Incident State:*

Incident Zip:*

Fully Describe What Happened:*

Consequence or Harm:

How Has This Affected Your Views or Trust:

Permission

Permission Help:

('I understand that by my filling out this form, only the above information along with my name and address will be shared with legislators. My experience may also be shared on the NVIC.org or the NVICAdvocacy.org website or the NVIC Facebook account to help bring attention to these problems, however all of my personal contact information will be kept in confidence and will only be used by NVIC so that we may communicate with you about your experience, if necessary.')

Name:*

Email:*

Confirm Email:*

Address:*

City:*

State:*

Zip:*

Country:

Work Phone:

Home Phone:

Security Code:

Enter the case sensitive code shown above in the box below

* required Submit Cancel