Milvacs - Add New Person
Please complete the fields below to be entered into the Data Base of the Ill. Your identity and contact information are not shared with anyone unless you check the final box below – or later, send us your express written permission via e-mail in response to a request. This is a two-step process: We will contact you to verify your information once you submit this form; then we will sort out your information, and post it.
First Name:
Last Name:
Gender: N/A Male Female
Rank:
Service:
Address:
:
City:
State:
Zip:
Country:
Birth Month (mm):
Birth Day (dd):
Birth Year (yyyy):
Phone Number:
Email Address:
Wish to Remain Anonymous Online: Yes No
Please give us as much specific information as possible regarding the shots you've had (lot number, dates), reactions to shots, and treatements you've received:



Enter Verification Code Shown Above:




Please give us as much specific information as possible regarding the shots you've had. Ideally, we want to know the following:

  • The type of shot you had (anthrax, smallpox, etc.)


  • Whether it was your first, second, or third shot in the series (or more)


  • What lot number that shot came from


  • What date you had the shot


  • What your reactions were to each shot, if possible


  • Whether or not you received medical treatment at any particular care center (Walter Reed for a civilian center, for example)


  • Whether or not you filed a VAERS report, and what VAERS number you were assigned


  • Where you were stationed when you got the shot


  • What your symptoms and diagnoses are


  • If a member of your immediate family - a spouse or children - seems to have been affected somehow by your inoculations, we want to know that, too
If you have a gender-neutral name, please let us know if you are male or female! You may provide as much information as you wish, but those are the basics that we hope for. To see why we ask for information this specific, please visit the Data Base of the Ill at http://milvacs.org/sickdb/reports.cfm and try using the search screens for a little bit.

If you don't have some of this information, please tell us your story anyway, and we will sort things out as best we can. There are records in the Data Base of the Ill that have come through without lot numbers, for example, but we still enter them.

Thank you very much for your participation. Please let others know about our work, and encourage them to participate as well.