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Do I Qualify for the National Vaccine Compensation Program?

PERSONAL INFORMATION

First Name:

Last Name:

E-mail Address:

Address:

City:

State:

Zipcode:

Phone:

() - ext.

INJURED PERSON INFORMATION

Date of Birth:

For whom are you inquiring about?

If you are NOT inquiring on your own behalf, what is your relationship?

Is the person deceased?

Yes No

If deceased, the cause of death as stated on the death certificate:

Date of Death:

Was there an autopsy performed?

Yes No

INJURY INFORMATION

Has person had any of the following injuries within 48 hours of recieving the vaccination:

Encephalopathy
Stroke
Heart Attack
Brain Injury

Death
Seizure
Guillian-Barre Syndrome

DRUG INFORMATION

Has person had any of the following vaccinations:

Tetanus
Pertussis
Measles
Mumps
Chicken Pox (Varicella)
MMR
Rubella

Polio
Hepatitis B
Rotavirus (Rotashield)
Flu Shot
DTaP
DPT

Other:

Dates that Vaccine(s) were given?

Did behavior regress after receiving vaccines?

Yes No

If yes, please describe regressive behavior:

Other Information:

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