Prepare Your Report

Use this information template to draft your experience before you file with the official state board. Nothing you enter here is collected or stored by this site when using the information template. You can save a local PDF or copy the text.

Information Template

Date of Injection

Date Symptoms Recognized

Date Treatment Sought

Physician Name

License Number

Medical Specialty

Practice / Organization Name

Location

Product

Harm / Adverse Effect

Details / What Happened (You are encouraged to personalize the template below)

I received the COVID modRNA gene treatment under the direction of Dr. (doctors name). (# of days/weeks) later I developed (symptoms). I was evaluated at (medical facility) and diagnosed with (adverse/serious adverse event). Indicate if the doctor dismissed your association between the onset of the symptoms and the preceding injection. Please also indicate if the doctor failed or declined your request to report your adverse event following the treatment to VAERS which is required.

Our goal is to provide you with information and assisstance for reporting your experience. Read and attach the supporting documentation following your personal experience. Before adding the file below to your report template, you may include additional documentation you believe pertinent.

Open support PDF Download PDF

Optional actions

Save a local copy (PDF) A PDF is saved on your device only.

Copy text to clipboard Copies the generated report text.

We do not store your report content. Use the options above to save or copy your information locally, then file your report on the official state site.

Tips

Be factual and chronological. Avoid speculation; stick to what you observed or have in records.
If you don’t know an exact date/time, write your best estimate and say it’s approximate.
Keep copies of related medical record available. Boards may request uploads on their official portals.
After saving your draft, go to the Complaint Portal to file with your state board.