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Submitted URL: https://coronavirusvaccineinjury.org/
Effective URL: https://icandecide.org/report-a-vaccine-injury/
Submission: On December 12 via api from JP — Scanned from JP
Effective URL: https://icandecide.org/report-a-vaccine-injury/
Submission: On December 12 via api from JP — Scanned from JP
Form analysis 1 forms found in the DOM
<form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required">Fields marked with an <span class="ninja-forms-req-symbol">*</span> are required</div>
</nf-section></div>
<div class="nf-form-content "><nf-fields-wrap><nf-field>
<div id="nf-field-12-container" class="nf-field-container textbox-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-12-wrap" class="field-wrap textbox-wrap" data-field-id="12">
<div class="nf-field-label"><label for="nf-field-12" id="nf-label-field-12" class="">Name <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-12" name="nf-field-12" aria-invalid="false" aria-describedby="nf-error-12" aria-labelledby="nf-label-field-12" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-12" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-13-container" class="nf-field-container email-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-13-wrap" class="field-wrap email-wrap" data-field-id="13">
<div class="nf-field-label"><label for="nf-field-13" id="nf-label-field-13" class="">Email <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-13" name="email" autocomplete="email" aria-invalid="false" aria-describedby="nf-error-13" aria-labelledby="nf-label-field-13" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-13" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-16-container" class="nf-field-container phone-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-16-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="16">
<div class="nf-field-label"><label for="nf-field-16" id="nf-label-field-16" class="">Phone <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-16" name="phone" autocomplete="tel" aria-invalid="false" aria-describedby="nf-error-16" aria-labelledby="nf-label-field-16" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-16" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-17-container" class="nf-field-container zip-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-17-wrap" class="field-wrap zip-wrap" data-field-id="17">
<div class="nf-field-label"><label for="nf-field-17" id="nf-label-field-17" class="">ZIP Code <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-17" name="zip" autocomplete="postal-code" aria-invalid="false" aria-describedby="nf-error-17" aria-labelledby="nf-label-field-17" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-17" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-18-container" class="nf-field-container date-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-18-wrap" class="field-wrap date-wrap" data-field-id="18">
<div class="nf-field-label"><label for="nf-field-18" id="nf-label-field-18" class="">Approximate Date Vaccine Received <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<div class="pikaday__container"><!-- Pikaday mentions were added for backwards compatibility -->
<input id="nf-field-18" name="nf-field-18" aria-invalid="false" aria-describedby="nf-error-18" class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday flatpickr-input"
aria-labelledby="nf-label-field-18" required="" type="hidden" value=""><input class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday form-control input" placeholder="" required="" tabindex="0"
type="text">
</div>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-18" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-19-container" class="nf-field-container textbox-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-19-wrap" class="field-wrap textbox-wrap" data-field-id="19">
<div class="nf-field-label"><label for="nf-field-19" id="nf-label-field-19" class="">Vaccine(s) Received <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-19" name="nf-field-19" aria-invalid="false" aria-describedby="nf-error-19" aria-labelledby="nf-label-field-19" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-19" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-20-container" class="nf-field-container textbox-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-20-wrap" class="field-wrap textbox-wrap" data-field-id="20">
<div class="nf-field-label"><label for="nf-field-20" id="nf-label-field-20" class="">How long after vaccine did injury begin <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-20" name="nf-field-20" aria-invalid="false" aria-describedby="nf-error-20" aria-labelledby="nf-label-field-20" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-20" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-14-container" class="nf-field-container textarea-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-14-wrap" class="field-wrap textarea-wrap" data-field-id="14">
<div class="nf-field-label"><label for="nf-field-14" id="nf-label-field-14" class="">Description of the injury <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<textarea id="nf-field-14" name="nf-field-14" aria-invalid="false" aria-describedby="nf-error-14" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-14" required=""></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-14" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-21-container" class="nf-field-container date-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-21-wrap" class="field-wrap date-wrap" data-field-id="21">
<div class="nf-field-label"><label for="nf-field-21" id="nf-label-field-21" class="">Date of birth <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<div class="pikaday__container"><!-- Pikaday mentions were added for backwards compatibility -->
<input id="nf-field-21" name="nf-field-21" aria-invalid="false" aria-describedby="nf-error-21" class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday flatpickr-input"
aria-labelledby="nf-label-field-21" required="" type="hidden" value=""><input class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday form-control input" placeholder="" required="" tabindex="0"
type="text">
</div>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-21" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-35-container" class="nf-field-container textbox-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-35-wrap" class="field-wrap textbox-wrap" data-field-id="35">
<div class="nf-field-label"><label for="nf-field-35" id="nf-label-field-35" class="">Sex <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-35" name="nf-field-35" aria-invalid="false" aria-describedby="nf-error-35" aria-labelledby="nf-label-field-35" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-35" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-23-container" class="nf-field-container date-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-23-wrap" class="field-wrap date-wrap" data-field-id="23">
<div class="nf-field-label"><label for="nf-field-23" id="nf-label-field-23" class="">Date and time of vaccination <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<div class="pikaday__container"><!-- Pikaday mentions were added for backwards compatibility -->
<input id="nf-field-23" name="nf-field-23" aria-invalid="false" aria-describedby="nf-error-23" class="ninja-forms-field date-and-time nf-element datepicker pikaday__display pikaday__display--pikaday flatpickr-input"
aria-labelledby="nf-label-field-23" required="" type="hidden" value=""><input class="ninja-forms-field date-and-time nf-element datepicker pikaday__display pikaday__display--pikaday form-control input" placeholder="" required=""
tabindex="0" type="text">
</div>
<div style="float:left;">
<select class="hour extra">
<option value="12">12</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
</select>
</div>
<div style="float:left;">
<select class="minute extra">
<option value="00">00</option>
<option value="05">05</option>
<option value="10">10</option>
<option value="15">15</option>
<option value="20">20</option>
<option value="25">25</option>
<option value="30">30</option>
<option value="35">35</option>
<option value="40">40</option>
<option value="45">45</option>
<option value="50">50</option>
<option value="55">55</option>
</select>
</div>
<div style="float:left;"><select class="ampm extra">
<option value="am">AM</option>
<option value="pm">PM</option>
</select></div>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-23" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-24-container" class="nf-field-container date-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-24-wrap" class="field-wrap date-wrap" data-field-id="24">
<div class="nf-field-label"><label for="nf-field-24" id="nf-label-field-24" class="">Date and time the adverse event (health problem) started <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<div class="pikaday__container"><!-- Pikaday mentions were added for backwards compatibility -->
<input id="nf-field-24" name="nf-field-24" aria-invalid="false" aria-describedby="nf-error-24" class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday flatpickr-input"
aria-labelledby="nf-label-field-24" required="" type="hidden" value=""><input class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday form-control input" placeholder="" required="" tabindex="0"
type="text">
</div>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-24" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-25-container" class="nf-field-container number-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-25-wrap" class="field-wrap number-wrap" data-field-id="25">
<div class="nf-field-label"><label for="nf-field-25" id="nf-label-field-25" class="">Age at vaccination <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input id="nf-field-25" name="nf-field-25" aria-invalid="false" aria-describedby="nf-error-25" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-25" required="" type="number" value="" min="1" max="125" step="1"
placeholder="1">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-25" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-26-container" class="nf-field-container date-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-26-wrap" class="field-wrap date-wrap" data-field-id="26">
<div class="nf-field-label"><label for="nf-field-26" id="nf-label-field-26" class="">Pregnancy due date (if applicable) </label></div>
<div class="nf-field-element">
<div class="pikaday__container"><!-- Pikaday mentions were added for backwards compatibility -->
<input id="nf-field-26" name="nf-field-26" aria-invalid="false" aria-describedby="nf-error-26" class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday flatpickr-input"
aria-labelledby="nf-label-field-26" type="hidden" value=""><input class="ninja-forms-field nf-element datepicker pikaday__display pikaday__display--pikaday form-control input" placeholder="" tabindex="0" type="text">
</div>
</div>
<div class="nf-field-description">
<p>Whether the patient was pregnant at the time of vaccination and the due date<br></p>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-26" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-27-container" class="nf-field-container textarea-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-27-wrap" class="field-wrap textarea-wrap" data-field-id="27">
<div class="nf-field-label"><label for="nf-field-27" id="nf-label-field-27" class="">Any medications (or supplements) being taken <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<textarea id="nf-field-27" name="nf-field-27" aria-invalid="false" aria-describedby="nf-error-27" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-27" required=""></textarea>
</div>
<div class="nf-field-description">
<p>Prescriptions, over-the-counter medications, dietary supplements and herbal remedies being taken<br></p>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-27" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-28-container" class="nf-field-container textarea-container label-above ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-28-wrap" class="field-wrap textarea-wrap" data-field-id="28">
<div class="nf-field-label"><label for="nf-field-28" id="nf-label-field-28" class="">Allergies <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<textarea id="nf-field-28" name="nf-field-28" aria-invalid="false" aria-describedby="nf-error-28" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-28" required=""></textarea>
</div>
<div class="nf-field-description">
<p>Allergies to medications, food, or other products</p>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-28" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-36-container" class="nf-field-container checkbox-container label-right ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-36-wrap" class="field-wrap checkbox-wrap" data-field-id="36">
<div class="nf-field-label"><label for="nf-field-36" id="nf-label-field-36" class=""> <span class="ninja-forms-req-symbol">*</span> </label></div>
<div class="nf-field-element">
<input id="nf-field-36" name="nf-field-36" aria-describedby="nf-error-36" class="ninja-forms-field nf-element" type="checkbox" value="1" aria-labelledby="nf-label-field-36" required="">
</div>
<div class="nf-field-description">
<p><span class="wpcf7-form-control-wrap" data-name="gdpr"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required"><span class="wpcf7-list-item first last"><span class="wpcf7-list-item-label">By using this form
you agree with the storage and handling of your data by this website.</span></span></span></span><br></p>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-36" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field><nf-field>
<div id="nf-field-15-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-15-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="15">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-15" class="ninja-forms-field nf-element " type="button" value="Send Message">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-15" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-3" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label for="nf-field-hp-3" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-3" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value="">
</label>
</nf-section></div>
</nf-section></div>
</div>
</form>Text Content
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