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HEALTH & SCIENCE,  SOLUTIONS

UPDATED Form for Employees Whose Employers Are Requiring Covid-19 Injections

July 29, 2021 / 63 Comments

10-5-22 Updated Form. Disregard below and CLICK HERE for form.

The first version of this form was written in May by Corey’s Digs for The Solari Report, and has been updated this week by the Solari team to account for future events, as things evolve. Please review this important information, legal and medical resources, and form to submit to employers.

[NOTE TO EMPLOYEE: Be sure to document the date and time you submit the form to your employer; also document the date and time and their response if they refuse to sign it. Note that three other Solari Report forms1,2,3 are also available as downloadable PDFs: the “Family Financial Disclosure Form for Covid-19 Injections”; “Notice and Declaration of Parental Authority Requirement of Disclosure and Safety of Medical Treatment/s”; and “Form for Students Attending Colleges or Universities Requiring Covid-19 Injections under Emergency Use Authorization.”]

Introduction

The situation with Covid-19 injections is fluid and evolving rapidly. As of July 2021, three vaccines were being administered in the U.S. under Food and Drug Administration (FDA) emergency use authorization (EUA): the Pfizer-BioNTech and Moderna mRNA injections and the Janssen/Johnson & Johnson adenovirus-vectored injection.

The injections’ regulatory status could soon change. On July 16, the FDA granted priority review to Pfizer’s application for full approval (licensure) of its Covid-19 vaccine for those age 16 and up. Moderna and Johnson & Johnson are also preparing to seek full approval. FDA officials have pledged to issue a decision with respect to the Pfizer application within two months. And though “not intervening in the decision of government scientists,” President Biden predicts full approval by September or October.4

Approval would have significant workplace ramifications. Assuming one or more shots receives full approval, public health experts expect “a wave of Covid-19 vaccine mandates,” confidently anticipating that licensure will “remove a significant legal and public relations barrier for businesses…that want to”—or are being pressured to—require vaccinations for their employees.5 Even under EUA, one federal agency (the Department of Veterans Affairs) has already mandated (on July 26) the experimental injections for its health care personnel, setting a federal precedent for employee mandates that others may soon follow. That same day, the Department of Justice published an opinion stating that it is legal for “public and private entities” to mandate Covid vaccines despite the injections only being approved for emergency use.

American workers who do not wish to accept Covid-19 injections are thus in a difficult position. The genesis of this form was to provide a tool for employees to use within the context of emergency use authorization with employers who attempt to mandate still-investigational Covid-19 injections (Scenario 1). With the possibility of full FDA approval in fall 2021 (Scenario 2), the legal context for U.S. mandates will likely shift in significant ways. In the event of licensure, we will provide an updated form that reflects the altered regulatory circumstances.

Under both scenarios, we anticipate that a form of this type will remain a critically important tool for employees determined to educate employers about the full set of physical and financial risks they are asking workers to incur. Employees should strongly consider reviewing the form with employers and also sharing it with co-workers. This could result in a positive outcome for employees and, if used widely, could be a game-changer.

Scenario 1: Emergency Use Authorization

Many employers are trying to deny employees’ right to choose and their right to bodily integrity by requiring EUA Covid-19 vaccines as a condition of employment. Under EUA, however, such requirements are a violation of the law. (We anticipate that the Department of Justice opinion on the legality of EUA mandates should and will be challenged.) Mandates are also a violation of fundamental human and religious rights.

The provisions of the 2005 Public Readiness and Emergency Preparedness (PREP) Act and a February 2020 declaration by the U.S. Department of Health and Human Services (HHS) Secretary mean that pharmaceutical companies cannot be held liable for injuries or deaths caused by EUA Covid-19 injections.6 However, other companies, institutions, and individuals can be held liable.

On the grounds that the injections are under EUA and are not formally licensed, many health care providers are refusing service to individuals injured by the Covid-19 injections, and health and life insurance companies are declining coverage for vaccine-related injuries and deaths.7 This denial of care and coverage poses a serious threat to the physical and financial well-being of employees presented with a requirement to get a Covid injection—perhaps even more so than the possibility of losing their job for not being vaccinated. Medical bills for vaccinated individuals with serious injuries have already exceeded $1 million in some cases.8 Under the PREP act, the vaccine-injured may submit a claim to the Countermeasures Injury Compensation Program (CICP), but the CICP historically has rejected 92% of claims and has not yet compensated a single Covid injection claim.9

Reviewing this form with employers may open their eyes to the regulations in place and the liability they may face (that they may otherwise not be aware of). If an employee should decide to accept the required experimental Covid-19 injection, the form also provides a mechanism to insist on a signature from the employer’s representative that holds the company liable. If the employer’s representative refuses to sign the form, that may be an indicator of the company’s concerns about potential liability and should prompt an immediate discussion about how the employee can continue working for the company without being injected.

Scenario 2: Full Approval

Before Covid-19, workplace vaccine mandates for adults were on a state-by-state basis and primarily focused on hepatitis B and influenza vaccination in health care settings, often allowing some accommodation for disability or religious beliefs.10 Under a scenario of full FDA approval for Covid-19 injections, a broader cross-section of employers well beyond the health care arena will likely feel emboldened or pressured to impose workplace mandates.11 Evoking the specter of “potentially severe” Covid illness, some commentators are suggesting that the process for granting medical or religious exemptions “may look a little different” (i.e., be more restrictive).12

If Covid-19 injections lose their EUA status and receive full FDA approval, they would no longer enjoy the liability protection conferred by the PREP Act. However, if the FDA extends full approval to children under age 18—as is widely anticipated13—and the Centers for Disease Control and Prevention (CDC) recommends Covid-19 injections for “routine administration” to children (or pregnant women),14 manufacturers and health care providers will be protected from liability for Covid-vaccine-related injuries and deaths under the 1986 National Childhood Vaccine Injury Act (NCVIA).15 From that point on, the only avenue available for compensation would be the notoriously stingy and difficult-to-navigate National Vaccine Injury Compensation Program (NVICP).16

Notes

1. The Solari Report. Family Financial Disclosure Form for Covid-19 injections. Mar. 1, 2021; updated Jul. 28, 2021. https://pandemic.solari.com/family-financial-disclosure-form-for-covid-19-injections/.
2. The Solari Report. Notice and Declaration of Parental Authority Requirement of Disclosure and Safety of Medical Treatment/s. Jun. 24, 2021. https://home.solari.com/notice-and-declaration-of-parental-authority-requirement-of-disclosure-and-safety-of-medical-treatment-s/.
3. The Solari Report. Form for Students Attending Colleges or Universities Requiring Covid-19 Injections under Emergency Use Authorization. May 4, 2021; updated Jul. 28, 2021. https://pandemic.solari.com/form-for-students-attending-colleges-or-universities-requiring-covid-19-injections/.
4. Weiland N, Karni A. Biden predicts the F.D.A. will give final approval to a Covid vaccine by the fall. The New York Times, Jul. 21, 2021.
5. Pettypiece S. Vaccine mandates more likely once FDA grants full approvals, health experts say. NBC, Jul. 20, 2021.
6. Congressional Research Service. The PREP Act and COVID-19: Limiting Liability for Medical Countermeasures. Updated Mar. 19, 2021. https://crsreports.congress.gov/product/pdf/LSB/LSB10443.
7. Del Bigtree interviews 3 medical professionals incapacitated by Covid injections. The Highwire, Apr. 29, 2021. https://www.bitchute.com/video/A4d8FB2cIBTc/.
8. Redshaw M. Woman who nearly died after J&J vaccine stuck with $1 million medical bill, says government should pay. The Defender, Jun. 2, 2021. https://childrenshealthdefense.org/defender/woman-nearly-died-johnson-johnson-vaccine-million-dollar-medical-bill/.
9. Redshaw M. Woman with “life-altering” injuries after COVID vaccine teams up with U.S. senators to demand answers. The Defender, Jul. 14, 2021. https://childrenshealthdefense.org/defender/brianne-dressen-injuries-astrazeneca-covid-vaccine-senators-demand-answer/.
10. National Vaccine Information Center. What laws exist to protect employees and adults from vaccine mandates? https://www.nvic.org/faqs/employee-vaccine-mandates.aspx.
11. Mulligan K, Harris JE. Opinion: More employers should mandates COVID-19 vaccines for workers — for the health of their business. MarketWatch, Jul. 21, 2021.
12. Schnalzer R. Newsletter: Can employers require workers to get flu shots? Los Angeles Times, Sep. 29, 2021.
13. Edwards E. Covid vaccines for kids under 12 expected midwinter, FDA official says. NBC, Jul. 15, 2021.
14. Health Resources & Services Administration. Covered vaccines. https://www.hrsa.gov/vaccine-compensation/covered-vaccines/index.html.
15. Children’s Health Defense. NCVIA: The legislation that changed everything—Conflicts of Interest Undermine Children’s Health: Part II. May 16, 2019. https://childrenshealthdefense.org/news/ncvia-the-legislation-that-changed-everything-conflicts-of-interest-undermine-childrens-health-part-ii/.
16. Children’s Health Defense. $4 billion and growing: U.S. payouts for vaccine injuries and deaths keep climbing. Nov. 19, 2018. https://childrenshealthdefense.org/news/4-billion-and-growing-u-s-payouts-for-vaccine-injuries-and-deaths-keep-climbing/.

Legal Resources

If you find yourself in a predicament with a company that refuses to hear you out, does not provide you with required information, or threatens termination of your employment, here are a few potential resources for attorneys:

Medical/Scientific Resources

Comprehensive, high-integrity medical and scientific information, including briefs and reports summarizing what is known about the risks of Covid-19 injections and adverse events, is available (and routinely updated) at the following websites:

  • America’s Frontline Doctors: In addition to its legal resources (see above), AFLDS’ website includes information about Covid-19 treatments, “issue briefs” on post-vaccination complications and other topics, and numerous other resources.
    https://americasfrontlinedoctors.org/about-us/mission-statement/
  • Children’s Health Defense (CHD): In addition to reporting on vaccine safety topics via its flagship online news outlet The Defender, CHD offers a “Fighting COVID Mandates” toolkit and related resources, a series of eBooks (including eBooks on vaccine mandates and protection of individual rights), a research library, and a “Community Corner.”
    https://childrenshealthdefense.org/
  • Doctors for COVID Ethics (D4CE): Among the excellent resources provided by this group of doctors and scientists from 30 countries are “Letter to physicians: Four new scientific discoveries regarding the safety and efficacy of COVID-19 vaccines,” which warns that “all physicians must reconsider the ethical issues surrounding COVID-19 vaccination,” and a 23-page Expert Statement outlining the serious risks of the Pfizer injection (European brand name Comirnaty) in children.
    https://doctors4covidethics.org/

Form for Employers Requiring Covid-19 Injections under Emergency Use Authorization

NOTE TO EMPLOYER: As your employee, I request that you review this document, provide the requisite information, and sign the form, in regards to your requirement that employees get a Covid-19 emergency use authorization (EUA) investigational vaccine.

1) If I agree to receive an EUA Covid-19 injection, does my employee health insurance plan provide complete coverage should I experience an adverse event, or even death?

___________________________________________________________________________________

___________________________________________________________________________________

2) As an employee, does my life insurance policy provide any coverage in the event that I die from receiving an EUA Covid-19 injection?

___________________________________________________________________________________

___________________________________________________________________________________

3) As an employee, will you be providing Workers’ Compensation, disability insurance, or other resources if I have an adverse event to an EUA Covid-19 injection and am unable to come to work for days, weeks, or months, or if I am disabled for life?

___________________________________________________________________________________

___________________________________________________________________________________

4) The Food and Drug Administration (FDA) requires that EUA vaccine recipients be provided with certain vaccine-specific information to help them make an informed decision about vaccination.1 The EUA fact sheets that must be provided are specific to each authorized Covid-19 injection and are developed by the manufacturers (Pfizer/BioNTech, Moderna, and Janssen/Johnson & Johnson). The fact sheets must provide up-to-date information on the injections and their ingredients; vaccine recipients must also receive information about adverse events. Have you read, understood, and provided me (and all other employees) with these fact sheets and current information on adverse events—and can you furnish a list of vaccine ingredients guaranteed to be complete—so that I/we can make an educated decision?

___________________________________________________________________________________

___________________________________________________________________________________

5) Have you reviewed the material adverse events experienced to date by people who have received EUA Covid-19 injections, reported to the Vaccine Adverse Event Reporting System (VAERS)?2 Reported adverse events include death, anaphylaxis, blood clots and related complications, heart problems (myocarditis and pericarditis), neurological disorders, autoimmune disorders, other chronic and inflammatory conditions, blindness and deafness, infertility, fetal damage, miscarriage, and stillbirth.

___________________________________________________________________________________

___________________________________________________________________________________

6) The FDA’s guidance3 on emergency use authorization of medical products requires the FDA to “ensure that recipients are informed to the extent practicable given the applicable circumstances…[t]hat they have the option to accept or refuse the EUA product…” Are you aware of this statement? Have you informed all employees that they have the option to refuse?
___________________________________________________________________________________

___________________________________________________________________________________

7) With respect to the emergency use of an unapproved product, the Federal Food, Drug and Cosmetic Act, Title 21 U.S.C. 360bbb-3(e)(1)(A)(ii)(I-III) reiterates that individuals be informed of “the option to accept or refuse administration of the product, [and] of the consequences, if any, of refusing administration of the product, and of the alternatives to the product that are available and of their benefits and risks.”4 In the event that the FDA decided to grant full approval to Covid-19 vaccines, state legislation would be required to allow companies to mandate the Covid-19 injections. Are you aware of these facts?

___________________________________________________________________________________

___________________________________________________________________________________

8) EUA products are unapproved, unlicensed, and experimental. Under the Nuremberg Code—the foundation of ethical medicine—no one may be coerced to participate in a medical experiment. The individual’s consent is absolutely essential. No court has ever upheld a mandate for an EUA vaccine. In Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003),5 a federal court held that the U.S. military could not mandate EUA vaccines for soldiers: “[T]he United States cannot demand that members of the armed forces also serve as guinea pigs for experimental drugs” (Id. at 135). Are you aware of this?

___________________________________________________________________________________

___________________________________________________________________________________
9) The United States Code of Federal Regulations6 and the FDA require the informed consent of human subjects for medical research. The EUA Covid-19 injections are unapproved, unlicensed, investigational vaccines that are still in their experimental stage. It is unlawful to conduct medical research on a human being, even in the event of an emergency, unless steps are taken to secure the full informed consent of all participants. Are you aware of this?

___________________________________________________________________________________

___________________________________________________________________________________

10) According to Federal Trade Commission (FTC) Guidelines7 and the FTC’s “Truth In Advertising,”8 promotional materials—and especially materials involving health-related products—cannot mislead consumers, omit important information, or express claims. All of this falls under the rubric of “deceptive advertising” (whereby a company is providing or endorsing a product), whether presented in the form of an ad, on a website, through email, on a poster, or in the mail. For example, statements such as “all employees are required to get the Covid-19 vaccine to make the workspace safe” or “it’s safe and effective” leave out critical information. Critical information includes the facts that Covid-19 injections are unapproved EUA vaccines that “may” or “may not” prevent Covid, won’t necessarily make the workplace safer, and could in fact cause harm. Not providing links or attachments of the manufacturers’ fact sheets and current information on adverse events is omitting safety information. Are you aware of this?

___________________________________________________________________________________

___________________________________________________________________________________

11) Since the Covid lockdowns began over one year ago, there have been over 178 reported breaches of unsecured protected health information (PHI), incidents investigated by the Office for Civil Rights (OCR). These breaches exposed millions of people’s personal health information. Although many of these incidents were attributed to hacking, some of the breaches to PHI fell directly under the 1996 Health Insurance Portability and Accountability Act (HIPAA), such as sharing a patient’s or person’s information with an unauthorized individual or incorrectly handling PHI.9 Can you please explain your obligations to me, under HIPAA law, with respect to your requirement that I receive this injection?

________________________________________________________________________________

________________________________________________________________________________

12) Whereas pharmaceutical companies that manufacture EUA vaccines have been protected from liability related to injuries or deaths caused by experimental agents since the Public Readiness and Emergency Preparedness (PREP) Act10 was enacted in 2005, companies and all other institutions or individuals who mandate experimental vaccines on any human being are not protected from liability. Are you aware that you do not enjoy such liability protection?

________________________________________________________________________________

________________________________________________________________________________

13) Are you aware that employees could file a civil suit against you should they suffer an adverse event, death, or termination from their place of employment?

________________________________________________________________________________

________________________________________________________________________________

As the legally authorized officer of the employer/company, I have read all of the above information, have provided my employees with all of the information that the FDA requires be provided to recipients of the Covid-19 injections, and do hereby agree to assume 100% financial responsibility for covering any and all expenses from adverse events, including death, through insurance coverage or directly. In addition, I affirm that the employee will not be subjected to the loss of their job should they decline to receive a Covid-19 injection.

Endnotes:

1. Centers for Disease Control and Prevention. COVID-19 Vaccine Emergency Use Authorization (EUA) Fact Sheets for Recipients and Caregivers. https://www.cdc.gov/vaccines/covid-19/eua/index.html.

2. In the United States, see Vaccine Adverse Event Reporting System, https://vaers.hhs.gov; CDC WONDER, “About the Vaccine Adverse Event Reporting System (VAERS),” https://wonder.cdc.gov/vaers.html; National Vaccine Information Center, “Search the U.S. Government’s VAERS Data,” https://www.medalerts.org/.

3. U.S. Department of Health and Human Services. Emergency Use Authorization of Medical Products and Related Authorities: Guidance for Industry and Other Stakeholders. January 2017. https://www.fda.gov/media/97321/download.

4. 21 U.S. Code § 360bbb–3 – Authorization for medical products for use in emergencies. https://www.law.cornell.edu/uscode/text/21/360bbb-3.

5. Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003). https://www.courtlistener.com/opinion/2326816/doe-v-rumsfeld/.

6. https://www.govregs.com/regulations/expand/title21_chapterI_part50_subpartB_section50.24#regulation_2.

7. Federal Trade Commission. Advertising FAQ’s: A Guide for Small Business. https://www.ftc.gov/tips-advice/business-center/guidance/advertising-faqs-guide-small-business.

8. Federal Trade Commission. Truth in Advertising. https://www.ftc.gov/news-events/media-resources/truth-advertising.

9. U.S. Department of Health and Human Services. Office for Civil Rights. Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information. https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf;jsessionid=618E88DD94EE65D46D5785CB2A643553.

10. Congressional Research Service. The PREP Act and COVID-19: Limiting Liability for Medical Countermeasures. Updated Mar. 19, 2021. https://crsreports.congress.gov/product/pdf/LSB/LSB10443.

Download the Employee form in PDF format. >
Download the Student form in PDF format. >

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Corey Lynn is an investigative journalist, co-host of the weekly Dig It! podcast, and co-host of The Solution Series. Follow her at coreysdigs.com, on Twitter, Gab, Truth, Rumble, and Telegram. Support her work by becoming a Patron, making a donation or buying a Book.

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63 Comments

  • Nikki

    May 5, 2021 at 5:27 am Reply

    Thank you for compiling this information. I work for the University of Illinois and they will require employees to become vaccinated prior to returning to campus in August. I have a preexisting gut condition and after having emergency surgery, I had a complete relapse of my GI tract because of receiving IV medications and antibiotics. Followup testing proved my relapse was due to the meds I was given during that procedure. The last thing I want to do is inflict more experimental chemicals into my body while I’m treating a problem with natural medicines. I did not know what I could do or where to start to even look for help. This has given me hope that I can continue to work and not receive the vaccine. Thank you!

  • Michael l Javick

    May 5, 2021 at 6:37 am Reply

    Sorry, But this IS A COMPLETE WASTE OF TIME…NO company will sign it. Amerika has been destroyed… You have no clue what is coming next…hint..there will NOT be enough left alive to BURY THE DEAD !

  • Miriam

    May 5, 2021 at 9:50 am Reply

    This is most interesting. However, what is missing in my POV, is the lawful standing of ANY MAN or WOMAN in the role as a CEO to have the audacity to even command medical intervention without having to give reason or explanation why or how the company was impacted by corona. There are no studies, no clinical trials, there was no mass-extinction of personnel to be witnessed by ANY of these employers. So, ANY law that prohibits trespass of a man or woman by another man or woman by way of extortion is still in place and in full effect. So, ANY authority a man/a woman as an employer has is restricted to health protection directly in proportion to the actual work. Having a flu, a frenzy media and some lunatic colluding politicians CLAIMING a catastrophe day in day out that simply was and is NOT visible IN ANY COMPANY (except for the missing personal due to stupid quarantine) and mandating a physical medical intervention from other men and women or they lose a job is simply criminal extortion. THAT is what men and women who sometimes act as employers should be held accountable for PRIVATELY. Medical interventions are NON of their business. HIIPA law or not. A man forcing another man to do a medical intervention against his will IS de facto unacceptable. And as of now there is NO LAW IN THE WORLD, that could even make it possible, as all superior law is still in effect that prohibits that.
    Employers! You cross the line with this.

  • Laura Rasgorshek

    May 5, 2021 at 11:03 am Reply

    Hi, Corey,

    Thank you for all of your great investigational reporting! What happens once the vaccines receive full FDA approval? I recently read that Pfizer and Moderna will both soon be filing for full approval. Once they receive full FDA approval, do we have any legal grounds against an employer or school requiring the vaccine?

    Thanks,
    Laura

  • DE Prata

    May 5, 2021 at 11:09 am Reply

    This document doesn’t have any legal standing. Most employers have “at-will” contracts and can terminate employees for any reason without repercussions. Most of the questions, “are you aware of this?” can be answered yes and will have zero effect legally. Get a good lawyer that can reword this document that shows that the vaccine goes against the existing employment contract and file a cease and desist motion in court. You still may get terminated for “insubordination” or some other minor issue. Threaten legal action at the hint of forced inoculations.

  • Jesse

    May 6, 2021 at 9:28 am Reply

    There’s a glaring problem here; the elephant in the room.

    What compensation should be entitled to if you for losing your job AFTER making a life altering decision like receiving a blood injection?

  • Dipak

    May 6, 2021 at 11:50 am Reply

    Very useful application and information. Every people of world should thanks to Carrie made and teem who prepared this draft.
    Vaccination is a way to to hell. 🙏

  • Janice Mcshane

    May 7, 2021 at 4:50 pm Reply

    Do you have a forms for for schools such as colleges? My son transferred to a college in January. In order to attend in the fall they want him to get a Covid-19 vaccine. He asked if he could go online but was told he had to switch majors. So he switched to another college for the fall semester. After all the paper work was finished the new college came out today stating they are also requiring fall students to get this experimental vaccine.

  • Jennifer Purdon

    May 10, 2021 at 10:18 am Reply

    Unfortunately this is so long no one in my HR department will take the time to read it. They’re all flaming liberals drinking the kovid koolaid and have already been vaxxed. It’s just a matter of time before they force us to do it. I too would like to see one of these, but much shorter, to use with businesses I.e. airlines. Thanks Corey!

  • Still Learning

    May 10, 2021 at 11:44 am Reply

    I don’t know if anyone has mentioned this yet but i think there is a typo:

    “3) As an employee”

    Shouldn’t that read “employer” as the employer is the one that needs to answer the question?

    I have not read past this point bc i was afraid I’d get busy and forget to say anything, but I’m sure it’s otherwise excellent work, as always, Corey!

    I’ve been a patron for a while now and you Never disappoint!

    May GOD continue to keep you in His strength and wisdom for you to fulfill His calling in this good work. In the Mighty Name of our Salvation, Jesus, The Christ!

    Respectfully,

    Still Learning

  • Mike

    May 11, 2021 at 5:35 pm Reply

    Thank you, Corey!

    As a vendor to certain public academic institutions, I am concerned that my clients may demand injections of myself and my crew.

    Can you please create a document that adjusts language to address small business concerns as vendors to large institutions sympathetic to the injections?

    Thank you so much!

  • CH

    May 20, 2021 at 7:34 pm Reply

    “COVID-19 injections”? Oh are you kidding? I do NOT want to received an injection of the disease. 🤣🤣🤣

  • Alice Smith

    May 21, 2021 at 6:07 pm Reply

    MICHAEL L JAVICK, you wrote: “Sorry, But this IS A COMPLETE WASTE OF TIME…NO company will sign it.”

    Of course, no company will sign it. That’s the point. If they refuse to sign it, they have no right to ask you to take the shot. This is one awesome document to hand to an employer. It’s worth it’s weight in gold and may very well save lives.

  • John Faber

    May 23, 2021 at 7:44 am Reply

    Since this injection in NO way complies with the definition of a “vaccine”, it seems that an informed document should not refer to the injection as such. In fact, that might be a good paragraph to add to the document!!

  • Feber James

    June 3, 2021 at 5:08 pm Reply

    So was this written by a teenager? It’s definitely not written by anyone who has a clue about writing contracts (or any other kind of agreement).

  • anarchyst

    June 4, 2021 at 5:54 pm Reply

    Obtain a fake CDC COVID-19 vaccination certificate and fill it out yourself. These can easily be created on card stock which mimics the “real” thing.

  • Marci

    June 24, 2021 at 1:03 am Reply

    Husband is career military (32 years, with 3 years to go before full retirement) and will be claiming exemptions for both health (he’s experienced dangerous reaction in past to prior smallpox jab) and religious reasons (as Christians, use of aborted fetal cells is a hard no). The thought that he could be forfeiting his entire military career and resulting retirement (at his senior rank, no less) due to this horrific experiment is almost too much for me to fathom. We are both in agreement, though, that this is the price he may have to pay for standing up for what’s right. He has many fellow soldiers (including chaplains) planning to do the same thing and so he will be in very good company. We are devastated at what the U.S. military has become (it’s a mere shell of itself), and are having a difficult time processing the reality facing us and so many other brave men and women who refuse to be used as part of an experiment yet again. Anthrax nearly did us all in and he won’t be making that same mistake again. Please pray for our military; the coercion going on is not being reported, but it is very much happening daily. While I realize that my husband has technically “signed his life away” as so many are quick to point out, this is a global culling to anyone with eyes to see and ears to hear. They’re going to get the shock of their lives when a large segment of our military walks away and doesn’t look back.

    • Corey Lynn

      June 24, 2021 at 1:10 am Reply

      I am so sorry you and your husband are going through this. It is absolutely horrific what is being done to the men and women in our military. I’m glad he has fellow soldiers willing to stand up to it. No one should allow themselves to be experimented on. Sending many prayers your way.

  • Charlotte

    June 29, 2021 at 11:40 am Reply

    Hi,

    I work in the medical field and my employer is requiring the vaccine for employees due to, from what I understand, a emergency standard set by OSHA. Can anyone explain if this document will assist in this new regulation?
    I’m feeling very violated and pressured to choose the safety and sanctity of my body or my livelihood.

    Thank you!
    – Charlotte

  • Sw

    July 11, 2021 at 12:10 am Reply

    Any ideas how a college student could use this when the school hasn’t “required” the jab but are making life so hard on the unvax that they are being pretty much forced to get it and left with no real choice. Being tested differently, quarantined, masking testing etc applied to only the unvax. Desperate to a solution.

  • Christopher

    July 23, 2021 at 8:56 pm Reply

    Does this form still apply when the FDA approves it for regular use they are anticipating in September? Reading it throughout it says unapproved.

  • AbbeyN

    July 25, 2021 at 10:52 am Reply

    I have been hearing from other military people that they are intentionally making it difficult for the unvax & non “progressives” (basically the true patriots) in order to weaken our military & get the good ones out. This is in order to replace the military with who they want to be there. Soon after, this is how guns will be taken from us. Because no “true” patriot would go against his country or the rights of its citizens.

  • Janis Rough

    July 31, 2021 at 10:15 am Reply

    Does anyone have concrete evidence or information that the vax has a microsystem that is traceable in any way if even in the future?

  • Barbara Spanne

    July 31, 2021 at 2:12 pm Reply

    I am an airline crew employee . Can you email me a pdf of this form so I can print it and give it to my airline CEO?
    Thank you

  • Victoria

    July 31, 2021 at 3:39 pm Reply

    Well it’s fun and all to theorize that you might make your employer read and sign this document. I don’t care if it was even something that might happen, I’m still not taking the vaccine. I have a right to refuse even if they offer me money. This form is a waste of time, resources and I wish they had spent the time focusing on points of law pertaining to our rights

  • Gavin

    July 31, 2021 at 3:58 pm Reply

    Thank you Corey for this great work. Please, has anyone got one that can be used in the UK ,we really , really appreciate your help x

  • Tina

    July 31, 2021 at 6:38 pm Reply

    Corey, Thankyou for all you do for people. A lot of businesses are going to be owned by people that live and have taken the jab. It’s already began, hospitals! Most people that they don’t scare are going to tell them to go pound sand. People are dropping like flies from these shots. Sad. They want to weaken our first responders and military. (Satanists) Please stand strong. Sad that the medical community are so indoctrinated. Thankyou, Corey.

  • Erica

    August 20, 2021 at 9:55 am Reply

    Great site! Thank you on behalf of everyone for Ann your work! Do you have language for those who are faced with the dilemma: jab or weekly testing? The tests are awful too!

  • Nate

    August 20, 2021 at 11:17 pm Reply

    Hello,
    Thank you for creating this form. The City of Los Angeles is about to mandate full vaccination of all employees upon the FDA’s full approval of the Covid-19 vaccines. Do you have a form for full approval?
    Thank you.

  • Jhon Waterman

    August 22, 2021 at 12:32 pm Reply

    Why is it that back in the 40’s and 50’s, with their limited scientific research, relative to today’s, viruses such as Polio, measles, etc could be isolated and a vaccine could be created by using the dead virus as a base for your own body to effectively create anti-bodies? Yet with todays scientific technology they can’t even isolate the corona virus in order to create a proven method of creating a vaccine? Makes me wonder if this virus even exsists…….

  • Deanna

    September 4, 2021 at 1:28 am Reply

    Although the media is reporting Pfizer has fully approved, it’s not. They extended the EUA, that’s it. It has not been fully approved. Please read the form in it’s entirety. It is not fully approved.

  • CJ

    September 9, 2021 at 12:28 pm Reply

    Hello Corey:

    Thank you. Question: given that a certain agency has approved the jab as of 17 days ago, do you have another updated version of the form for employees that they can present to their employers? I’ve looked it over and I keep seeing mention of IF the jab is approved, as well as the EUA status it formerly had. I have the earlier version posted above, but also have some ideas about how to update it but would need some guidance very soon, in regards to a notification that just came out today. Thanks again and looking forward to hearing back.

  • Laura Beck

    September 12, 2021 at 5:36 pm Reply

    I think the point is being missed here. I don’t know about the rest of you, but I would NOT want my employer to sign the form because I have no intention of taking the jab. The point is for them to refuse to sign and back off.

  • Amy Polzin

    October 4, 2021 at 5:48 pm Reply

    Now that the FDA has approved Pfizer, will you be updating the forms appropriately soon? I have one week to submit a religious exemption.

  • Amy

    October 5, 2021 at 8:52 am Reply

    I’ve heard that before. But I need proof. Where can I get detailed information about which Pfizer v has been approved and which is still being administered? Thank you.

  • SB

    April 4, 2022 at 2:45 pm Reply

    Do we have any updated notices now that Cominarty exists and is “FDA approved”? I can’t find anything to help me with that…

  • Sophie Blumenthal

    June 21, 2022 at 2:22 pm Reply

    I wanted to get some answers. I was terminated for non-compliance last December on this vaccination and then rehired back in January and am kicked out again for non-compliance. What documents do i need to get some my employer explaining why I was rehired.

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