Vaccine Injury Compensation Inquiry Form

Your Name:
Street Address:
City:

State: Choose State: Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Washington DC Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota N. Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Phone Number:

E-mail Address:

Name of individual suffering the adverse reaction:

Date of birth of individual suffering the adverse reaction:

Date of vaccinations:

Types of vaccines administered - please put all:

Date the initial symptoms of the adverse reaction occurred:

Date of first medical visit concerning the initial symptoms:

Please describe the adverse reaction experienced:

Please describe the health at present of the individual suffering the adverse reaction: