Reporting Vaccination Harassment, Discrimination and Coercion Incidents

Please fill out one form per incident. Thank you.









Incident Details
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('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.')
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