Form for Employees Whose Employers Are Requiring Covid-19 Injections
NOTE TO EMPLOYEE: Be sure to document the date and time you submit this form to your employer; also document the date and time and their response if they refuse to sign it.
NOTE TO EMPLOYER: As your employee, I am requesting that you review this document, provide the requisite information, and sign the form, in regards to your requirement that employees get a Covid19 emergency use authorization (EUA) investigational vaccine.
1) If I agree to receive an EUA Covid-19 injection, does my employee health insurance plan provide complete coverage should I experience an adverse event, or even death?____________________________________________________________________________________________________________________________________
2) As an employee, does my life insurance policy provide any coverage in the event that I die from receiving an EUA Covid-19 injection? ______________________________________________________________________________________________________________________________________
3) As an employee, will you be providing Workers’ Compensation, disability insurance, or other resources if I have an adverse event to an EUA Covid-19 injection and am unable to come to work for days, weeks, or months, or if I am disabled for life? ____________________________________________________________________________________________________________________________________
4) The Food and Drug Administration (FDA) requires that EUA vaccine recipients be provided with certain vaccine-specific information to help them make an informed decision about vaccination. 8 The EUA fact sheets that must be provided are specific to each authorized Covid-19 injection and are developed by the manufacturers of the injections (Pfzer/BioNTech, Moderna, Oxford/AstraZeneca, and the Johnson & Johnson subsidiary Janssen). The fact sheets must provide the most current and up-to-date information on the injections, and vaccine recipients must also receive information about adverse events. Have you read, understood, and provided me (and all other employees) with these fact sheets and with current information on adverse events so that I/we can make an educated decision? ____________________________________________________________________________________________________________________________
5) Have you reviewed the available databases of material adverse events reported to date for people who have received Covid-19 injections? 9,10,11,12 Potential and reported adverse events include death, anaphylaxis, neurological disorders, autoimmune disorders, other long-term chronic diseases, blindness and deafness, infertility, fetal damage, miscarriage, and stillbirth. ___________________________________________________________________________________________________________________
6) The FDA’s guidance13 on emergency use authorization of medical products requires the FDA to “ensure that recipients are informed to the extent practicable given the applicable circumstances… [t]hat they have the option to accept or refuse the EUA product….” Are you aware of this statement? Have you informed all employees that they have the option to refuse? _________________________________________________________________________________________________________________________
7) With respect to the emergency use of an unapproved product, the Federal Food, Drug and Cosmetic Act, Title 21 U.S.C. 360bbb-3(e)(1)(A)(ii)(I-III)14 reiterates that individuals be informed of “the option to accept or refuse administration of the product, [and] of the consequences, if any, of refusing administration of the product, and of the alternatives to the product that are available and of their benefits and risks.” If EUA Covid-19 investigational vaccines are ever approved by the FDA, state legislation would be required to allow companies to mandate the Covid-19 injections. Are you aware of these facts?
8) EUA products are unapproved, unlicensed, and experimental. Under the Nuremberg Code—the foundation of ethical medicine—no one may be coerced to participate in a medical experiment. The individual’s consent is absolutely essential. No court has ever upheld a mandate for an EUA vaccine. In Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003)15 , a federal court held that the U.S. military could not mandate EUA vaccines for soldiers: “...[T]he United States cannot demand that members of the armed forces also serve as guinea pigs for experimental drugs” (Id. at 135). Are you aware of this?
9) The United States Code of Federal Regulatons16 and the FDA require the informed consent of human subjects for medical research. The EUA Covid-19 injections are unapproved, unlicensed, investigational vaccines that are still in their experimental stage. It is unlawful to conduct medical research on a human being, even in the event of an emergency, unless steps are taken to secure the informed consent of all participants. Are you aware of this? _____________________________________________________
10) According to Federal Trade Commission (FTC) Guidelines17 and the FTC’s “Truth In Advertising,”18 promotonal material—and especially material involving health-related products—cannot mislead consumers, omit important information, or express claims. All of this falls under the rubric of “deceptive advertising” (whereby a company is providing or endorsing a product), whether presented in the form of an ad, on a website, through email, on a poster, or in the mail. For example, statements such as “all employees are required to get the Covid-19 vaccine to make the workspace safe” or “it’s safe and effective” leave out critical information. Critical information includes the facts that Covid-19 injectons are unapproved EUA vaccines that “may” or “may not” prevent Covid, won’t necessarily make the workspace safer, and could in fact cause harm. Not providing links or attachments of the manufacturers’ fact sheets and current information on adverse events is omitting safety information. Are you aware of this? ___________________________________________________________________________________________________________________
11) Since the Covid lockdowns began over one year ago, there have been over 178 reported breaches of unsecured protected health information (PHI), incidents investigated by the Office for Civil Rights (OCR). These breaches exposed millions of people’s personal health information. Although many of these incidents were attributed to hacking, some of the breaches to PHI fell directly under the 1996 Health Insurance Portability and Accountability Act (HIPAA), such as sharing a patent’s or person’s information with an unauthorized individual or incorrectly handling PHI.19 Can you please explain your obligations to me, under HIPAA law, and how you are going to protect my personal information - both with respect to your requirement that I receive this injection? __________________________________________________________________________________________________________________________________
12) Whereas pharmaceutical companies that manufacture EUA vaccines have been protected from liability related to injuries or deaths caused by experimental agents since the PREP Act1 was enacted in 2005, companies and all other institutions or individuals who mandate experimental vaccines on any human being are not protected from liability. Are you aware that you do not enjoy such liability protection?
13) Are you aware that employees could file a civil suit against you should they suffer an adverse event, death, or termination from their place of employment?
As the legally authorized officer of the employer/company, I have read all of the above information, have provided my employees with all of the information that the FDA requires be provided to recipients of the Covid-19 injections, and do hereby agree to assume 100% financial responsibility for covering any and all expenses from adverse events, including death, through insurance coverage or directly. In addition, I affirm that the employee will not be subjected to the loss of their job should they decline to receive a Covid-19 injection.
_______________________________________________________ _____________________________________ ________________ Authorized Officer of Company requiring injection Company Date
_______________________________________________________ _____________________________________ ________________ Employee Company Date
________________________________________________________ ___________________________________ _________________ Witness Company Date
Endnotes: 1. Congressional Research Service. The PREP Act and COVID-19: Limiting Liability for Medical Countermeasures. Updated Mar. 19, 2021. htps://crsreports.congress.gov/product/pdf/LSB/LSB10443. 2. Del Bigtree interviews 3 medical professionals incapacitated by Covid injections. The Highwire, Apr. 29, 2021. htps://www.bitchute.com/video/A4d8FB2cIBTc/. 3. America’s Frontline Doctors. Vaccines & the law. htps://www.americasfrontlinedoctors.org/legal/vaccines-the-law. 4. Layton, Catharine. Forced to get the COVID vaccine? ICAN may be able to help. The Defender, Jan. 29, 2021. htps://childrenshealthdefense.org/defender/forced-to-get-covid-vaccine-ican-may-be-able-to-help/.5. htps://uscfc.uscourts.gov/sites/default/fles/Vaccine%20Atorneys.pdf. 6. The Solari Report. Family Financial Disclosure Form for Covid-19 injections. Mar. 1, 2021. htps://pandemic.solari.com/familyfnancial-disclosure-form-for-covid-19-injectons/. 7. Corey Lynn, The Solari Report. Form for Students Attending Colleges or Universities Requiring Covid-19 Injections. May 3, 2021. 8. Centers for Disease Control and Prevention. COVID-19 Vaccine Emergency Use Authorization (EUA) Fact Sheets for Recipients and Caregivers. htps://www.cdc.gov/vaccines/covid-19/eua/index.html. 9. UK Medical Freedom Alliance. COVID-19 Vaccine Info. htps://www.ukmedfreedom.org/resources/covid-19-vaccine-info. 10. Vaccine Adverse Event Reporting System. htps://vaers.hhs.gov. 11. CDC WONDER. About the Vaccine Adverse Event Reporting System (VAERS). htps://wonder.cdc.gov/vaers.html. 12. National Vaccine Information Center. Search the U.S. Government’s VAERS Data. htps://www.medalerts.org/. 13. U.S. Department of Health and Human Services. Emergency Use Authorization of Medical Products and Related Authorities: Guidance for Industry and Other Stakeholders. January 2017. htps://www.fda.gov/media/97321/download. 14. 21 U.S. Code § 360bbb–3 - Authorization for medical products for use in emergencies. htps://www.law.cornell.edu/uscode/text/21/360bbb-3. 15. Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003). htps://www.courtlistener.com/opinion/2326816/doe-v-rumsfeld/. 16. htps://www.govregs.com/regulatons/expand/ttle21_chapterI_part50_subpartB_secton50.24#regulaton_2. 17. Federal Trade Commission. Advertising FAQ’s: A Guide for Small Business. htps://www.fc.gov/tps-advice/businesscenter/guidance/advertsing-faqs-guide-small-business. 18. Federal Trade Commission. Truth in Advertising. htps://www.fc.gov/news-events/media-resources/truth-advertsing. 19. U.S. Department of Health and Human Services. Office for Civil Rights. Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information. htps://ocrportal.hhs.gov/ocr/breach/breach_report.jsf;jsessionid=618E88DD94EE65D46D5785CB2A643553. 20. .htp://market-tcker.org/akcs-www?post=242282 21. htps://www.natlawreview.com/artcle/osha-s-new-guidance-recordability-covid-19-vaccine-reacton