Vaccine Damage Reporting System Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *City of Residence *State of Residence (copy) *Hospital/Location where vaccine injury occurred. *Was a VAERS report was filed for your vaccine injury? *NoYesI don't knowIf YES, do you have the VAERS case #?Have you sought legal counsel for your vaccine injury? *NoYesDo you feel your vaccine injury is something that should be pursued legally? *YesNo May our Truth for Health Foundation team contact you about your vaccine injury? *Yes, Truth for Health Foundation may contact me about my vaccine injury. Submit