Adverse Event Data Collection Form

AERT Data Collection & Consent

Your Experience - Data Collection & Consent Form

All fields marked with a * must be completed.


'Mandated Out' - Consent Form

All fields marked with a * must be completed.


Thank you for sharing your story of being 'mandated out' with us. To save your details into the Citizens' Database please complete the required fields to submit the form. If you would also like to tell us about an adverse event to your health following vaccination, check the box below and complete the necessary details.

If your story related to another person, that individual needs to complete this form themselves. Please forward them the email.

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 requested).

This form is responsive - new sections will open up in response to the answers you give.

Your Details


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 Deceased Person


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 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


CARM Reports


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 email The Health Forum NZ directly (reports@thehealthforumnz.co.nz), to give their express consent.

Tell Your Story in a "Selfie Video"


The Health Forum NZ are creating a short video to help New Zealanders learn about the type of serious ongoing life changing vaccine injuries that many are now living with in our country.

Follow the instructions here for recording your video, ensuring it is:

  • recorded on your phone
  • 20 seconds long
  • landscape orientation
  • contains your name, age and adverse event details

Please also upload a high quality photo of yourself.

Further Information


Supporting evidence


Were you working in Education?


Thank you

After submitting this form a Adverse Events Team volunteer will contact you to confirm receipt, and request any further clarification required. Please check your SPAM folder for emails.

You will also receive a copy of this form to your email address.


Thank you

After submitting this form, the volunteer you have been in contact with will confirm receipt via email and clarify any further details required. Please check your SPAM folder for emails.

You will also receive a copy of this form to your email address.


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.