Form for USA based Employees Whose Employers Are Requiring Covid-19 Injections

NOTE TO EMPLOYEE: Be sure to document the date and tme you submit this form to your employer; also document the date and tme and their response if they refuse to sign it. NOTE

TO EMPLOYER: As your employee, I am requestng that you review this document, provide the requisite informaton, and sign the form, in regards to your requirement that employees get a Covid19 emergency use authorizaton (EUA) investgatonal vaccine.





Congressional Research Service. The PREP Act and COVID-19: Limitng Liability for Medical Countermeasures. Updated Mar.
19, 2021. htps://

Del Bigtree interviews 3 medical professionals incapacitated by Covid injectons. The Highwire, Apr. 29, 2021.

America’s Frontline Doctors. Vaccines & the law. htps://
Layton, Catharine. Forced to get the COVID vaccine? ICAN may be able to help. The Defender, Jan. 29, 20




The Solari Report. Family Financial Disclosure Form for Covid-19 injectons. Mar. 1, 2021. htps://

Corey Lynn, The Solari Report. Form for Students Atending Colleges or Universites Requiring Covid-19 Injectons. May 3,

Centers for Disease Control and Preventon. COVID-19 Vaccine Emergency Use Authorizaton (EUA) Fact Sheets for Recipients
and Caregivers. htps://

UK Medical Freedom Alliance. COVID-19 Vaccine Info. htps://
Vaccine Adverse Event Reportng System. htps://

CDC WONDER. About the Vaccine Adverse Event Reportng System (VAERS). htps://

Natonal Vaccine Informaton Center. Search the U.S. Government’s VAERS Data. htps://

U.S. Department of Health and Human Services. Emergency Use Authorizaton of Medical Products and Related Authorites:
Guidance for Industry and Other Stakeholders. January 2017. htps://

21 U.S. Code § 360bbb–3 – Authorizaton for medical products for use in emergencies.

Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003). htps://

Federal Trade Commission. Advertsing FAQ’s: A Guide for Small Business. htps://

Federal Trade Commission. Truth in Advertsing. htps://

U.S. Department of Health and Human Services. Ofce for Civil Rights. Breach Portal: Notce to the Secretary of HHS Breach of
Unsecured Protected Health Informaton.
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