Adverse Effects Testimonial Questionnaire

Gathering of all victims of anti-covid injections in France and neighboring countries.

This questionnaire can help you testify on the French Victims map, in the Department where you reside.

Depending on whether you do not wish to communicate all of your identity or even provide a photo or not, your testimony will take on several different appearances.

Your presence on the victims' site will look like this:

Without Photo With Photo

Without a photo, the poster will never be printed and exhibited

in the tributes made by victim defense associations.

From which site did you arrive here?

AAVIC TEAM

ARESAJ74

AUTRE

NAME and first name of the victim

If minor, identity and relationship of the declarant

Your email

Municipality & Department of Residence

Date of birth

Number of doses received

Name of injections received

Lot number

Date of injections

Write down all your Adverse Effects here

Photo of applicant (optional...but preferable for credibility)

Choisissez un fichier

Formats de fichier : png, jpg, jpeg, pdf

I would like a poster to be created and distributed for Collectives and Associations

YES

I authorize the publication of the information, photo and attest to the authenticity of the information provided. Write “Good for Agreement” and write your “NAME and First name”

Anti-spam