Confidential Post-Vaccination Health Record (Anonymous)
Age group: 0-5 : 5-18 : 18-30 30-55 : 55-70 : 70+ :
Sex (optional) : (M or F) …
Covid vaccine brand/s: (ex : Pfizer + Moderna) …
Number of doses: (ex : 3)
Batch/lot numbers (if known): (ex : FE7010, EX0797, 008G21A) …
Symptoms experienced: …
Diagnoses (if any): …
Cause of death (if applicable): …
CONSENT SECTION
I confirm this information is accurate to the best of my knowledge
I understand this data is collected anonymously
I consent to my data being used for research/awareness purposes by VIAC19
Submissions relating to individuals under 18 must be completed by a parent or legal guardian.
I am the parent/legal guardian of the child
This form collects anonymised information about post-vaccination health experiences for the purpose of identifying and supporting shared understanding. Do NOT include names, addresses, or any information that could identify you or another person.
Each submission will be assigned a unique reference ID to ensure it remains anonymous. An anonymised summary of the data will be included in the UK datas et published on the VIAC19 website. No personally identifiable information will be shared. You have the right to withdraw your entry at any time. Data will be stored securely and accessed only by authorised individuals.
VIAC19 Dominique Baudinaud – Data Coordinator
