Submission Form -

C-19 Injection Injury or Death Report Form

Tips for completing this form.

Keep it as simple as possible, Under 600 words is ideal. Include facts that are verifiable with medical records. Avoid political commentary or defamatory statements that could be considered slander.

*Please note that we have no influence or control over what witness testimony is selected for any hearing or proceeding.

Thank you for making this submission and helping others by sharing your testimony.

Your name

Relationship To Patient

Is the patient a U.S. Citizen?

Yes No

Is the Patient a Minor?

Yes No

Name of Injured if different from yourself.

Was the shot required or coerced?

Yes No

Was the shot received as part of Military Service?

Yes No

About YOU

About the PATIENT (If not yourself)

Progression and Timeline

Your Email