Allison Inquiry | Listening to Canadian Covid-19 Vaccine Injured

Personal Information

Full Name *

Phone Number *

Email Address *

Alternate Contact Info *

Street Address *

City *

Province/State *

Postal Code/Zip Code *

Date of Birth *

Month

Day

Year

Sex *

How many Covid-19 vaccines (including any booster shots) have you received to date? *

Why do you want to provide a written testimony for the Allison inquiry's record? *

List the key points you want to cover in your written testimony regarding your Covid-19 vaccine injury. *

Consent

If you are asked to provide your medical records, you are allowed to edit them before you provide them. Do you consent to any medical records that you do provide to us forming part of the public record?YesNo

Part 1

Are you reporting on the injuries and/or death of another person?

If you are reporting on the injuries and/or death of another person what is your relationship to that person.

If you are reporting for another person, are you their legal guardian or do you have their permission to tell their story publicly? *

If you are reporting on the injuries and/or death of another person, how have the injuries and/or death affected you and/or your family?

Part 2 - For each Covid-19 vaccine you received (or if you are reporting on behalf of someone else), please provide:

Vaccination Information

Date of Vaccination

Month

Day

Year

Brand

Are you reporting on the injuries and/or death of another person?

Lot Number

What information about the vaccine were you given by the person(s) who administered the vaccine?

If you were told about any potential side effects, what were you told?

Were you given enough information to fully consent to the vaccination? If no explain.

What was the reaction to this vaccination?

When did the reaction start?

How has the reaction progressed - has it worsened, has it resolved, has it remained the same, etc? Be specific on your time periods.

Did the reaction affect a pre-existing condition. For example, did you have arthritis before vaccination, but your arthritis changed after a vaccination? If yes, provide details of the condition before the vaccination(s) as well as the changes.

Why do you believe the reaction was caused by a vaccine?

Do any medical professionals agree that the reaction was caused by the vaccine(s)?

Why did you take the vaccine(s)?

Add Another Vaccination Undo Add Vaccination

Part 3 - Suffering is difficult to explain to others. As best you can, explain how you have suffered.

How have your vaccine injuries affected your ability to care for yourself?

How have your vaccine injuries affected your employment and/or education?

How have your vaccine injuries affected you in your ability to socialize and pursue your interests?

How have your vaccine injuries affected your relationships, including your intimate relationships?

How have your vaccine injuries affected you mentally?

How have your vaccine injuries affected you spiritually?

How have your vaccine injuries affected you financially?

How have your vaccine injuries affected your family?

Were you affected by public communications about the vaccine(s)? If so how were you affected?

Did you feel compelled or pressured to take the vaccine(s)? If so explain.

How do you feel now about taking the vaccine(s)?

Part 4 - If you applied to the Vaccine Injury Program, fill in the below.

When did you apply?

Month

Day

Year

If you were awarded compensation how much did you receive?

Describe your experience with the Vaccine Injury Program.

Do you feel you were treated fairly? Explain.

What has been your experience with the medical system since taking the vaccine(s)?

Do you feel you were treated fairly? Explain.

Do you feel the medical system has been responsive to your injuries? Explain.

What has been your experience with medical officials?

What has been your experience with elected representatives?

Do you feel you were treated fairly? Explain.

Which persons or groups have been most helpful to you since you were injured. Explain.

Have your adverse reactions been reported to any government agency or injury reporting program. If yes, provide details.

Part 5

What message would you like to send to Parliament?

If you have any additional comments add them here.

Save as Draft

form3test

Personal Information

Consent

Part 1

Part 2 - For each Covid-19 vaccine you received (or if you are reporting on behalf of someone else), please provide:

Part 3 - Suffering is difficult to explain to others. As best you can, explain how you have suffered.

Part 4 - If you applied to the Vaccine Injury Program, fill in the below.

Part 5

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