Share your Experience

Your Experience - Data Collection & Consent Form

All fields marked with a * must be completed.


The Health Forum NZ are collating data regarding the impact of Covid-19 regulations into a confidential Citizens’ Database to record how people in NZ are being affected.

The information given to The Health Forum NZ via this form may be used anonymously for statistical analysis and reporting purposes. If you agree, your story may also be shared publicly (maintaining anonymity if required).

Once this form is completed, you must check your email and click the "CONFIRM YOUR SUBMISSION" button. This validates your email address and submits your form to us.

Your Experience


Details of Adverse Event

This section asks about personal details, doses received, and adverse events that occurred.


Unfortunately, we are unable to record events that did not occur in NZ.

Please complete the Consent and CAPTCHA below, then  Submit the form so we can record this fact.

About the Affected Person


About the Affected Person


About the Deceased Person


About the doses the affected person received

Please enter details for ALL doses received, even if you didn't have any symptoms following that dose. Press the + button to the right to add another dose.

Batch numbers may be found on your vaccination card, via your GP or online at My Covid Record.


About the Adverse Event

Add a new line with the + to the right if there was more than one episode of symptoms (eg after 1 day, then different symptoms starting after 2 weeks), or for a different dose.


About the death


How to report to CARM

The Health Forum NZ encourage you to report any suspected adverse event following Covid-19 vaccination to MedSafe using the online CARM form. You don’t have to be certain that the vaccine caused the event. https://report.vaccine.covid19.govt.nz/s/


Let us be your voice


If the affected person wishes to have their story shared publicly, please ask them to contact The Health Forum NZ directly.

Supporting evidence


Were you working in Education?


Thank you

Once you submit this form, please check your email and click the CONFIRM YOUR SUBMISSION button to save this data.

When your form has been accepted, you will be emailed a copy of it.


DISCLAIMER

The information that you provide via this form will be stored in The Health Forum NZ's electronic Citizens' Database. The Health Forum NZ is not liable for any inaccuracies in the information given to them. Any information that is found to be inaccurate or questionable will be removed. Data will only be used for anonymous statistical analysis and reporting of redacted data, unless permission is obtained for other purposes. The Citizens' Database is operating in compliance with the processes permitted by the Privacy Act 2020, and Health Information Privacy Code 2020.