Share your Experience THFNZ Data Collection & Consent (open)ReferrerYour Experience - Data Collection & Consent FormAll 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 requested). This form is responsive - new sections will open up in response to the answers you give. 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 DetailsYour full nameEmailMobile phone numberHome phone numberYour ExperienceHow have you (or the person you are reporting for) been impacted by Covid-19 regulations in NZ? (tick all that apply) Suffered an adverse event following vaccination Mandated out from work, study, etc Declined an exemption OtherWere you/they working or studying in any of these sectors at the time? Tick all that apply Health & Social care Education Emergency services Armed forces StudyingDetails of Adverse EventThis section asks about personal details, doses received, and adverse events that occurred.Did the adverse event occur in NZ? Yes NoUnfortunately, 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 PersonWho was the person who was affected? Yourself Someone elseIs this person A minor (under 18) Someone whom you have Powers of Attorney for Deceased Another adult I confirm that I have gained consent from the person stated to be the "Affected Person" to share their personal information with The Health Forum NZ for this purpose. About the Affected PersonName of affected personTheir relationship to you, eg. mother, sonAbout the Deceased PersonName of deceased personTheir relationship to youNHI (if known)Ethnicity- Select -NZ EuropeanMaoriTokelauaFijianNuieanTonganCook Island MaoriSamoanOther Pacific PeoplesSouth East AsianIndianChineseOther AsianLatin AmericanAfricanMiddle EasternOther EuropeanOtherTown/City of usual residenceOther ethnicity, not in listDate of birthAge when Adverse Event occurredGender- Select -MaleFemaleOtherPrefer not to sayPre-existing medical conditionsAbout the doses the affected person receivedPlease 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. Dose number (include all doses) Date of vaccination (include year) Type Batch number - Select -PfizerPfizer paediatricAstraZenecaNovavaxJanssen (J&J) About the Adverse EventAdd 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. Which dose? What were the symptoms? How long after vaccination did the symptoms START? What happened as a result? - Select -Unable to perform usual daily tasksBedriddenUnable to work/studyGP appointmentCalled HealthlineVisit to After hours / Urgent careWent to A&ERequired an ambulanceStayed in hospitalReferred to specialist Have you experienced any menstrual (period) changes or post-menopausal bleeding following any of the doses? (if not already detailed above) Which dose? Symptoms What happened as a result? - Select -Postmenopausal bleedingHeavy or prolonged menstruationPainful menstruationDelayed menstruation (missed period)Changes to cycle length (shorter/longer than usual) - Select -No problemsDifficult to perform daily actitiesUnable to go to work/studyConsulted GP/medical centreVisited Out of Hours / Urgent CareWent to A&ETaken in AmbulanceReferred to Specialist About the deathHow long after vaccination did the death occur?Date of deathTown/City of deathThe location of the deathCause of death on death certificateCARM ReportsHave the adverse events been reported to CARM/MedSafe? Yes NoHow to report to CARMThe 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/ Record each CARM reference number separately using the + to the right CARM reference number Symptoms that were reported Let us be your voiceWould you like your story shared publicly by The Health Forum NZ (anonymous if requested)? Yes No I/we hereby consent The Health Forum NZ to release or share information regarding my/our personal story. I/we reserve the right to withdraw consent at any time.I/we wish to remain anonymous in any published stories Yes NoIf the affected person wishes to have their story shared publicly, please ask them to contact The Health Forum NZ directly.Tell Your Story in a VideoIf you would like to create a short video about your situation, please follow include the following: recorded on your phone landscape orientation details of your life before the injection/mandate why you took the injection how your life has been affected since Upload Video Upload Photo for Montage Further informationUse this space to tell us your story, or give any other information you would like to have recorded.Supporting evidenceUpload any photos, scanned documents, or other files to support your storySelect Files to Upload Were you working in Education?Do you consent to your contact details being passed to a group of Education Sector workers interested in actions seeking Justice and reparation? Yes NoConsent & Privacy I have read and agree to the Privacy Statement. I declare that the information that I have given in this form is true and correct to be best of my knowledge. I agree that all information that I provide to representatives of The Health Forum NZ, past, future and present, may be stored electronically in the Citizens' Database.Checking you're humanClick below to select the images requested and complete the CAPTCHA.Thank youOnce 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.DISCLAIMERThe 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.Submit Form
