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Please use real names to help validate the story, but we can anonymize the victim's name prior to publishing if you prefer, just tell us during your interview.

Let others know about this person in a few words. Example: "Loving parent of 3 young sons" or "lit up the room," or "touched the lives of all who knew them".

Please share images from the victim's life that joyfully represent the person they were prior to this incident - you will have an opportunity to add photos of the abuse or injury later on.

How old was the victim at the time of injury?

Please tell us the sex of the victim.

Was the victim receiving Medicare or Medicaid benefits?

Was the victim insured at the time of hospitalization or injury?

If the victim had health insurance, please select your provider from this list. If the insurance provider is not listed, please scroll to the bottom of this list and select "Other" so you can input the insurer below.

If the victim had health insurance but their provider is not listed, please tell us the victim's health insurance provider.

Was the victim in the armed forces or police force?

If the victim served in the armed forces, what branch did they serve?

If the victim was considered special needs or had any kind of disability, please check the box.

If the victim was considered special needs or had any kind of disability, please tell us what disability or special needs the victim had.

Check the box if the victim is the subject being interviewed (if you are the victim), rather than a loved one.

The name of subject documenting this case and being interviewed - leave blank if subject is victim.

Your relationship to the victim, or the relationship of subject to victim.

The email address of the person being interviewed or the primary contact for this case. This will not be displayed on the site, but will be used for verification purposes.

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The phone number of the person being interviewed or the primary contact for this case. This will not be displayed on the site, but will be used for verification purposes.

In what state did the incident take place?

What was the zip code of the victim's residence during the time that this happened?

Where did the incident take place?

If you would like to talk with or meet with other victims and families of victims in your state, please check the box.

There are many different crimes against humanity taking place right now. Select all that are relevant to the experience you are documenting.

We know it's difficult to go over all the details, but telling your story in your own words is the most powerful way to convey it. Please take your time and tell us as much or as little as you are comfortable with. In the event that you absolutely cannot bring yourself to write it out, one of our volunteers may summarize your story based on the information you have provided and based on your interview. We prefer you tell your story, in as much detail as possible.

Which mandates played a factor in the victim's decisions that led to their harm or demise? Check all that apply.

Has this incident been reported to the federal Vaccine Adverse Events Reporting System (VAERS)?

Has this incident been reported to the federal Vaccine Adverse Events Reporting System (VAERS)?

Paste the content of the VAERS response below.

Has this incident been filed with the Countermeasures Injury Compensation Program (CICP)?

Provide your Countermeasures Injury Compensation Program (CICP) ID Number.

Paste the content of the CICP response below.

Elaborate on how mandates played a role in what happened to the victim.

Please check the box if the victim received any so-called COVID vaccines.

How many "vaccines" and "boosters" were administered to the victim before adverse reactions developed?

doses

How many "vaccines" and "boosters" were administered to the victim, in total?

doses

Was the victim informed that COVID vaccines only have Emergency Use Authorization from the FDA, and are not actually 'FDA approved'?

Was the victim informed of potential COVID-19 vaccine side effects before being given the injection?

Was the victim asked to sign a waiver or consent form in advance of being vaccinated?

Date of first COVID vaccination

If you know the brand of the first COVID vaccine the victim was administered, tell us here.

If you know the batch number for the first COVID vaccine the victim was administered, tell us here.

What brand of COVID vaccine was the victim injected with the second time?

If you know the batch number for the second vaccine the victim was administered, tell us here.

What brand of COVID vaccine was the victim injected with the third time?

If you know the batch number for the third vaccine the victim was administered, tell us here.

What brand of COVID vaccine was the victim injected with the fourth time?

If you know the batch number for the fourth vaccine the victim was administered, tell us here.

What brand of COVID vaccine was the victim injected with the fifth time?

If you know the batch number for the fifth vaccine the victim was administered, tell us here.

What brand of COVID vaccine was the victim injected with the sixth time?

If you know the batch number for the sixth vaccine the victim was administered, tell us here.

What brand of COVID vaccine was the victim injected with the seventh time?

If you know the batch number for the seventh vaccine the victim was administered, tell us here.

What brand of COVID vaccine was the victim injected with the eighth time?

If you know the batch number for the seventh vaccine the victim was administered, tell us here.

When did the victim first begin experiencing symptoms?

Please describe all symptoms experienced by the victim.

When did the victim first seek medical attention?

Tell us about the doctor or doctors involved in this case.

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What was the doctor's name?

On a scale of 1-10 where 1 is the worst possible and 10 is the best, please rate this doctor's performance.

Elaborate on how this doctor treated the victim, any notable exchanges, or anything else you think we might want to know about this doctor.
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Was the victim admitted to the hospital in relation to this case?

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Hospital(s) victim was admitted to during the course of this ordeal.

What is the zip code of the hospital where the victim was treated (or mistreated)?

The county that the hospital is located in.

When was the victim first admitted to the hospital?

While in the hospital, was the victim allowed to see family or given access to a patient advocate?

How many days was the victim isolated before being allowed contact with family or advocate?

Was the victim was asked if they had been vaccinated and/or boosted by doctors or hospital staff?

Does the victim or family feel they were treated differently by hospital staff as a result of disclosing their vaccination status?

If you believe the victim was treated differently by doctors and/or hospital staff after disclosing their vax status, please describe the experience.

Was the victim or the victim's family was asked to sign a Do Not Resuscitate order?

Was the victim deprived of food and water while in the hospital?

How many days was the victim deprived of food and water while in the hospital?

What medications were administered to the victim by doctors or hospital staff? Please check all you believe were administered.

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What medications did the hospital explicitly refuse to administer to the victim? Please check all you believe were administered.

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Was the victim informed that remdesivir has only Emergency Use Authorization from the FDA, and is not actually approved to treat COVID?

Was the victim informed of potential remdesivir side effects before being given the drug?

Did the victim or the family consent to the use of remdesivir?

How many days was the victim being administered remdesivir?

Was victim was placed on a ventilator?

When was the victim first put on a ventilator?

Has any medical professional given a diagnosis indicating what the victim is suffering from?

What was the victim diagnosed with? Check all that apply, or input your own selections.

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Generally, how was the victim treated while at the hospital?

Check all that apply. If you add an item that is not listed, keep it short: a few words or less.

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A brief summary of how the victim was treated in the hospital

Images that document hospital abuse, mistreatment, or neglect, or pictures that highlight 'vaccine' injuries can be uploaded here.

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If you would like to allow us to share these images publicly, please check the box. If you would like us to keep these on file for reference, leave the box unchecked.

You can tell us a few words about what is happening in this image if you like.
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Did the victim survive? Check the box if they lived to tell their story. Uncheck the box if they died as a result of what happened.

If there was a cause of death determined by officials, please check all that apply.

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What do you think killed the victim, or what does the family believe really killed their loved one?

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Medical records can help piece together what happened to the victim. Have you obtained, or do you plan to obtain a complete set of medical records?

Have discrepancies been identified in the medical records?

Is the victim or the family pursuing legal action against the doctor or hospital?

Has the victim or family already retained a lawyer or legal team to help with this case?

If the victim or family is pursuing legal action and has retained legal representation, who is representing them?

Is the victim or the family engaging in any activism as a result of this experience?

What victim or family doing to ensure this doesn't happen to anyone else? What is their advice for other families going through this experience? What do they believe should be done to bring justice to their loved one?

If there is a website or social media page associated with this story that you would like to include in your case, you can link to it here.

Is there anything else you think the world should know about what happened?

Use this field to note the date that the interview took place.

We hold a support group for victims of the FDA Death Protocol and their families, every Monday evening. The group would love it if you would join us and share your story with others who have been through this.

We have a task force seeking justice for victims of the FDA Death Protocol and their families, and pursuing action other issues essential to our liberty. Would you like to join The FFFF Task Force?

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Task Force members are organizing a series of podcasts highlighting these crimes against humanity and the assault on medical freedom. Would you be interested in participating in these podcasts?

How did you find this site?

Who referred you? Please tell us the volunteer's name, handle, or email address, if you know it.

Please tell us how you found out about this site.

By checking this box you agree to allow this site to publish the data on this form except where specified otherwise, to share the data with our partners, and to use this information in various ways as we pursue justice for all victims of these crimes against humanity.

After you press submit below, you will be prompted to schedule your interview. You must complete this step so that we can publish your story with the “Verified” label. If you do not complete an interview, your story may not be published.