{"id":56,"date":"2021-12-21T06:20:37","date_gmt":"2021-12-21T06:20:37","guid":{"rendered":"http:\/\/www.knightsofthecradle.com\/news\/?page_id=56"},"modified":"2021-12-22T03:28:39","modified_gmt":"2021-12-22T03:28:39","slug":"adverse-reaction-registry","status":"publish","type":"page","link":"http:\/\/www.knightsofthecradle.com\/news\/adverse-reaction-registry\/","title":{"rendered":"Adverse Reaction Registry"},"content":{"rendered":"<div class=\"boldgrid-section\">\n<div class=\"container\">\n<div class=\"row\" style=\"padding-top: 0px; padding-bottom: 0px;\">\n<div class=\"col-md-12 col-xs-12 col-sm-12\">\n<h2 class=\"\" style=\"text-align: center;\">Reporting a Vaccine Injury \/ Adverse Reaction<\/h2>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"boldgrid-section\">\n<div class=\"container\">\n<div class=\"row\" style=\"padding-top: 0px; padding-bottom: 0px;\">\n<div class=\"col-md-12 col-sm-12 col-xs-12\">\n<p class=\"\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-66 size-medium\" style=\"width: 100%;\" src=\"http:\/\/www.knightsofthecradle.com\/news\/wp-content\/uploads\/2021\/12\/0_249_900_199.6875_Vaccine-Basics-cropped-1.jpg\" alt=\"\" width=\"900\" height=\"199\"><\/p>\n<\/div>\n<\/div>\n<div class=\"row\" style=\"padding-top: 0px; padding-bottom: 50px;\">\n<div class=\"col-md-12 col-sm-12 col-xs-12\">\n<h2 class=\"\" style=\"text-align: center;\">Adverse Reaction \/ Injury Form<\/h2>\n<p class=\"\">Knights of the Cradle (Yort Knight) have set up a reporting system, relying on people to send in reports of their experience when taking a vaccine and the reactions \/ actions that occurred after. Anyone can fill out and submit a report to KOTC, including family, friends, doctors or report your own vaccine injury.<\/p>\n<p class=\"\">Feel free to share this page with anyone you know that would like to be involved in this movement and getting as much information out to public as possible. We do have bigger plans in the works involving anyone with a vaccine injury, and filling out the form below will help us know the details and keep in contact with you. YOU ARE NOT A STASTIC OR NUMBER. YOU ARE A PERSON WITH A FACE AND A STORY.&nbsp;<\/p>\n<p class=\"\" style=\"text-align: center;\"><span style=\"color: #b0abab;\">* PRIVACY STATEMENT *<\/span><br \/>\n<span style=\"color: #b0abab;\">All data collected will be treated as confidentially. Our aim is to set up a data base and have this information accessible to the general public so everyone is informed of the issues people are facing when taking a vaccine and the risks involved. No names or personal details will be shared. Any details provided WILL NOT be shared \/ sold or passed onto a third party unless we have your written consent before hand.<\/span><\/p>\n<p class=\"\">I would like to thank you all for taking the time to fill out the below form. I hope you are going well at the moment during this difficulted time. If you need help, please reach out to us and we will try to put you InTouch with the right people. May God be with you and guide you during these dark time. Take care xoxo<\/p>\n<div class=\"boldgrid-shortcode\" data-imhwpb-draggable=\"true\" style=\"padding: 2em; border-style: dashed; box-shadow: #cecece -1px 0px 0px 0px; background-color: #fbf9f8; border-color: #c4c4c3;\">\n<div class=\"widget wpforms-widget\"><div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-53\"><form id=\"wpforms-form-53\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"53\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/news\/wp-json\/wp\/v2\/pages\/56\" data-token=\"bed9b0b7a7c68a9794818045052e0e71\" data-token-time=\"1780192378\"><div class=\"wpforms-head-container\"><div class=\"wpforms-title\">Adverse Reactions Form<\/div><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-53-field_1-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"1\"><label class=\"wpforms-field-label\">I consent to Knight Of The Cradle collecting the information I have provided regarding my vaccine adverse reaction and using this to get information out to the general public to inform others of the issues involved. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_1\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_1_1\" name=\"wpforms[fields][1][]\" value=\"YES\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_1_1\">YES<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_39-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"39\"><label class=\"wpforms-field-label\">Name of the person filling out this form <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-53-field_39\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][39][first]\" required><label for=\"wpforms-53-field_39\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-53-field_39-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][39][last]\" required><label for=\"wpforms-53-field_39-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-53-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"2\"><label class=\"wpforms-field-label\">Details of the affected person <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-53-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" required><label for=\"wpforms-53-field_2\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-53-field_2-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][2][middle]\" ><label for=\"wpforms-53-field_2-middle\" class=\"wpforms-field-sublabel after\">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-53-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" required><label for=\"wpforms-53-field_2-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-53-field_41-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"41\"><label class=\"wpforms-field-label\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"email\" id=\"wpforms-53-field_41\" class=\"wpforms-field-required wpforms-field-email-primary\" name=\"wpforms[fields][41][primary]\" spellcheck=\"false\" required><label for=\"wpforms-53-field_41\" class=\"wpforms-field-sublabel after\">Email<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"email\" id=\"wpforms-53-field_41-secondary\" class=\"wpforms-field-email-secondary wpforms-field-required\" data-rule-confirm=\"#wpforms-53-field_41\" name=\"wpforms[fields][41][secondary]\" spellcheck=\"false\" required><label for=\"wpforms-53-field_41-secondary\" class=\"wpforms-field-sublabel after\">Confirm Email<\/label><\/div><\/div><\/div><div id=\"wpforms-53-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_33\">Age <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-53-field_33\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][33]\" required><\/div><div id=\"wpforms-53-field_3-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"3\"><label class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_3\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-53-field_3_1\" name=\"wpforms[fields][3]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_3_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-53-field_3_2\" name=\"wpforms[fields][3]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_3_2\">Female<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-53-field_3_4\" name=\"wpforms[fields][3]\" value=\"Prefer not to say\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_3_4\">Prefer not to say<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_5\">Your location - Town \/ State \/ Post Code  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-53-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" placeholder=\"Town (Melbourne), State (Vic\/Qld\/NSW), Post Code (3224)\" required><\/div><div id=\"wpforms-53-field_15-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_15\">Phone \/ Mobile<\/label><input type=\"number\" id=\"wpforms-53-field_15\" class=\"wpforms-field-small\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-53-field_6-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"6\"><label class=\"wpforms-field-label\">Are you filling this form out for yourself or someone you know? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_6_1\" name=\"wpforms[fields][6][]\" value=\"Myself\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_6_1\">Myself<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_6_2\" name=\"wpforms[fields][6][]\" value=\"Someone I know\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_6_2\">Someone I know<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_11\">If someone you know, please specify your relationship<\/label><input type=\"text\" id=\"wpforms-53-field_11\" class=\"wpforms-field-small\" name=\"wpforms[fields][11]\" placeholder=\"(Mum, Dad, Friend, Doctor, God Parent)\" ><\/div><div id=\"wpforms-53-field_45-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"45\"><label class=\"wpforms-field-label\">Main Reason(s) for getting vaccinated - (Tick as many relevant options) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_45\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_1\" name=\"wpforms[fields][45][]\" value=\"Protect Myself\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_1\">Protect Myself<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_2\" name=\"wpforms[fields][45][]\" value=\"Protect Family Members\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_2\">Protect Family Members<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_3\" name=\"wpforms[fields][45][]\" value=\"Loss of Employment\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_3\">Loss of Employment<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_16\" name=\"wpforms[fields][45][]\" value=\"Employee Insisted\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_16\">Employee Insisted<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_15\" name=\"wpforms[fields][45][]\" value=\"Hospital Insisted\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_15\">Hospital Insisted<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_14\" name=\"wpforms[fields][45][]\" value=\"Government said I had to\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_14\">Government said I had to<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_13\" name=\"wpforms[fields][45][]\" value=\"Teacher said so\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_13\">Teacher said so<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_12\" name=\"wpforms[fields][45][]\" value=\"Influenced by media \/ Celebrity\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_12\">Influenced by media \/ Celebrity<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_11\" name=\"wpforms[fields][45][]\" value=\"Advertising\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_11\">Advertising<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_10\" name=\"wpforms[fields][45][]\" value=\"Travel \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_10\">Travel<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_9\" name=\"wpforms[fields][45][]\" value=\"Booked entertainment required me to\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_9\">Booked entertainment required me to<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_8\" name=\"wpforms[fields][45][]\" value=\"Family Breakdown\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_8\">Family Breakdown<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_7\" name=\"wpforms[fields][45][]\" value=\"Education Requirement \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_7\">Education Requirement<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_6\" name=\"wpforms[fields][45][]\" value=\"Peer Pressure\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_6\">Peer Pressure<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_5\" name=\"wpforms[fields][45][]\" value=\"Still be involved in the community\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_5\">Still be involved in the community<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_45_4\" name=\"wpforms[fields][45][]\" value=\"Able to access shopping\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_45_4\">Able to access shopping<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_18\">If for other reason(s) - Please provide details<\/label><input type=\"text\" id=\"wpforms-53-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" ><\/div><div id=\"wpforms-53-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_26\">Who administered the vaccine? Doctor, Drive through clinic, Hospital staff? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-53-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" placeholder=\"(If Drive through clinic, please provide details)\" required><\/div><div id=\"wpforms-53-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"46\"><label class=\"wpforms-field-label\">Do you believe you were given informed consent? - Relevant information of the procedure you were undergoing? - (Tick as many relevant options) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_46\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_1\" name=\"wpforms[fields][46][]\" value=\"It was explained in full detail to me - Risks involved\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_1\">It was explained in full detail to me - Risks involved<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_2\" name=\"wpforms[fields][46][]\" value=\"Received product information document\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_2\">Received product information document<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_3\" name=\"wpforms[fields][46][]\" value=\"Did not receive any product information\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_3\">Did not receive any product information<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_25\" name=\"wpforms[fields][46][]\" value=\"Nobody explained the informed consent information\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_25\">Nobody explained the informed consent information<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_24\" name=\"wpforms[fields][46][]\" value=\"Was told the vaccine was safe\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_24\">Was told the vaccine was safe<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_23\" name=\"wpforms[fields][46][]\" value=\"Was told the side affects would be brief and harmless\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_23\">Was told the side affects would be brief and harmless<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_22\" name=\"wpforms[fields][46][]\" value=\"Was told the side affects were rare and probably not from the vaccine\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_22\">Was told the side affects were rare and probably not from the vaccine<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_21\" name=\"wpforms[fields][46][]\" value=\"Was told the vaccine could cause harm but it was worth the risk\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_21\">Was told the vaccine could cause harm but it was worth the risk<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_20\" name=\"wpforms[fields][46][]\" value=\"Was given time to reconsider and obtain a second opinion\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_20\">Was given time to reconsider and obtain a second opinion<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_46_19\" name=\"wpforms[fields][46][]\" value=\"Nobody said anything to me\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_46_19\">Nobody said anything to me<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_28-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"28\"><label class=\"wpforms-field-label\">Were you aware the vaccine companies hold NO liability to any injuries caused by the vaccine you had? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-53-field_28_1\" name=\"wpforms[fields][28]\" value=\"Yes, I knew this information\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_28_1\">Yes, I knew this information<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-53-field_28_2\" name=\"wpforms[fields][28]\" value=\"No, I did not know about this\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_28_2\">No, I did not know about this<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_8-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"8\"><label class=\"wpforms-field-label\">Which vaccine did you get? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Astrazeneca\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_8_1\">Astrazeneca<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_8_2\" name=\"wpforms[fields][8][]\" value=\"Moderna\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_8_2\">Moderna<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_8_3\" name=\"wpforms[fields][8][]\" value=\"Pfizer\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_8_3\">Pfizer<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_29-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"29\"><label class=\"wpforms-field-label\">What Information was collected \/ given at the time? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_29\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Medical Staff checked my medical history\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_29_1\">Medical Staff checked my medical history<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_29_2\" name=\"wpforms[fields][29][]\" value=\"Doctor checked my medical history\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_29_2\">Doctor checked my medical history<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_29_3\" name=\"wpforms[fields][29][]\" value=\"Nobody checked my medial history or asked me about it\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_29_3\">Nobody checked my medial history or asked me about it<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_29_8\" name=\"wpforms[fields][29][]\" value=\"I was given instructions on what to do if I had a reaction\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_29_8\">I was given instructions on what to do if I had a reaction<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_29_7\" name=\"wpforms[fields][29][]\" value=\"I was NOT given instructions on what to do if I had a reaction\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_29_7\">I was NOT given instructions on what to do if I had a reaction<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_29_6\" name=\"wpforms[fields][29][]\" value=\"I was advised that the TGA had a system for reporting and was given TGA&#039;s details\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_29_6\">I was advised that the TGA had a system for reporting and was given TGA's details<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_29_5\" name=\"wpforms[fields][29][]\" value=\"I was NOT advised of the TGA reporting system\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_29_5\">I was NOT advised of the TGA reporting system<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_40-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_40\">Further details about information collected before taking the vaccine<\/label><textarea id=\"wpforms-53-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" ><\/textarea><\/div><div id=\"wpforms-53-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_14\">Date of FIRST vaccination <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-53-field_14\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][14]\" placeholder=\"05\/09\/2021 - ?\" required><\/div><div id=\"wpforms-53-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_20\">Date of SECOND vaccination<\/label><input type=\"text\" id=\"wpforms-53-field_20\" class=\"wpforms-field-small\" name=\"wpforms[fields][20]\" placeholder=\"05\/09\/2021 - ?\" ><\/div><div id=\"wpforms-53-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_21\">Date of THIRD (Booster) vaccination<\/label><input type=\"text\" id=\"wpforms-53-field_21\" class=\"wpforms-field-small\" name=\"wpforms[fields][21]\" placeholder=\"05\/09\/2021 - ?\" ><\/div><div id=\"wpforms-53-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_17\">Adverse reaction time frame - How long from the time of taking the vaccine did you get a reaction? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-53-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" placeholder=\"(Date 07\/09\/2021) - (Approx 4 days) - (Around 3 hours) ?\" required><\/div><div id=\"wpforms-53-field_22-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_22\">Details of Adverse Reaction and duration at the start <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-53-field_22\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][22]\" placeholder=\"* Please provide as much detail as possible. \" required><\/textarea><\/div><div id=\"wpforms-53-field_47-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"47\"><label class=\"wpforms-field-label\">Did you report the reaction to anyone? (Tick as many relevant options) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_1\" name=\"wpforms[fields][47][]\" value=\"Doctor\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_1\">Doctor<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_2\" name=\"wpforms[fields][47][]\" value=\"Employee\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_2\">Employee<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_3\" name=\"wpforms[fields][47][]\" value=\"Hospital\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_3\">Hospital<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_13\" name=\"wpforms[fields][47][]\" value=\"TGA\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_13\">TGA<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_12\" name=\"wpforms[fields][47][]\" value=\"000 Ambulance was called\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_12\">000 Ambulance was called<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_11\" name=\"wpforms[fields][47][]\" value=\"000 Taken to hospital in Ambulance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_11\">000 Taken to hospital in Ambulance<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_10\" name=\"wpforms[fields][47][]\" value=\"Family\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_10\">Family<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_9\" name=\"wpforms[fields][47][]\" value=\"Partner\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_9\">Partner<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_47_8\" name=\"wpforms[fields][47][]\" value=\"Other - Give details below\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_47_8\">Other - Give details below<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_19\">If other - more information about reporting, please provide details below<\/label><input type=\"text\" id=\"wpforms-53-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-53-field_53-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"53\"><label class=\"wpforms-field-label\">Attitude of Medical authorities \/ Person you reported the reaction to <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_53\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_1\" name=\"wpforms[fields][53][]\" value=\"Cautioned\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_1\">Cautioned<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_2\" name=\"wpforms[fields][53][]\" value=\"Threatened\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_2\">Threatened<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_3\" name=\"wpforms[fields][53][]\" value=\"Kind and helpful\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_3\">Kind and helpful<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_15\" name=\"wpforms[fields][53][]\" value=\"Dismissive\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_15\">Dismissive<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_14\" name=\"wpforms[fields][53][]\" value=\"Listened and cared\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_14\">Listened and cared<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_13\" name=\"wpforms[fields][53][]\" value=\"Hostile\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_13\">Hostile<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_12\" name=\"wpforms[fields][53][]\" value=\"Denied vaccine caused any reaction\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_12\">Denied vaccine caused any reaction<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_11\" name=\"wpforms[fields][53][]\" value=\"Reported as vaccine adverse reaction\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_11\">Reported as vaccine adverse reaction<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_10\" name=\"wpforms[fields][53][]\" value=\"Attributed to covid and unvaccinated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_10\">Attributed to covid and unvaccinated<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_9\" name=\"wpforms[fields][53][]\" value=\"Described as rare\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_9\">Described as rare<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_8\" name=\"wpforms[fields][53][]\" value=\"Described as common\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_8\">Described as common<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_53_7\" name=\"wpforms[fields][53][]\" value=\"Inconclusive\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_53_7\">Inconclusive<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_30-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_30\">Attitude of Medical authorities \/ Person you reported the reaction to - Please provide details<\/label><textarea id=\"wpforms-53-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" ><\/textarea><\/div><div id=\"wpforms-53-field_48-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"48\"><label class=\"wpforms-field-label\">Vaccine Symptoms and Conditions (Tick as many relevant options) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_48\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_1\" name=\"wpforms[fields][48][]\" value=\"Allergic Reaction\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_1\">Allergic Reaction<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_2\" name=\"wpforms[fields][48][]\" value=\"Anaphylaxis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_2\">Anaphylaxis<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_3\" name=\"wpforms[fields][48][]\" value=\"Vaccinated and still got Covid\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_3\">Vaccinated and still got Covid<\/label><\/li><li class=\"choice-54 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_54\" name=\"wpforms[fields][48][]\" value=\"Anxiety\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_54\">Anxiety<\/label><\/li><li class=\"choice-64 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_64\" name=\"wpforms[fields][48][]\" value=\"Depression\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_64\">Depression<\/label><\/li><li class=\"choice-63 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_63\" name=\"wpforms[fields][48][]\" value=\"Arythmia\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_63\">Arythmia<\/label><\/li><li class=\"choice-62 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_62\" name=\"wpforms[fields][48][]\" value=\"Bell\u2019s palsy\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_62\">Bell\u2019s palsy<\/label><\/li><li class=\"choice-61 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_61\" name=\"wpforms[fields][48][]\" value=\"Bladder Control Problems\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_61\">Bladder Control Problems<\/label><\/li><li class=\"choice-60 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_60\" name=\"wpforms[fields][48][]\" value=\"Blood Clotting\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_60\">Blood Clotting<\/label><\/li><li class=\"choice-59 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_59\" name=\"wpforms[fields][48][]\" value=\"Blood pressure problems\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_59\">Blood pressure problems<\/label><\/li><li class=\"choice-58 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_58\" name=\"wpforms[fields][48][]\" value=\"Body tremors\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_58\">Body tremors<\/label><\/li><li class=\"choice-57 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_57\" name=\"wpforms[fields][48][]\" value=\"Body Spasms\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_57\">Body Spasms<\/label><\/li><li class=\"choice-56 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_56\" name=\"wpforms[fields][48][]\" value=\"Bone density loss\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_56\">Bone density loss<\/label><\/li><li class=\"choice-55 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_55\" name=\"wpforms[fields][48][]\" value=\"Cancer \u2013 return of former symptoms\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_55\">Cancer \u2013 return of former symptoms<\/label><\/li><li class=\"choice-53 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_53\" name=\"wpforms[fields][48][]\" value=\"Cancer \u2013 new symptoms\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_53\">Cancer \u2013 new symptoms<\/label><\/li><li class=\"choice-52 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_52\" name=\"wpforms[fields][48][]\" value=\"Chronic Fatigue Syndrome\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_52\">Chronic Fatigue Syndrome<\/label><\/li><li class=\"choice-51 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_51\" name=\"wpforms[fields][48][]\" value=\"Cognitive disability\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_51\">Cognitive disability<\/label><\/li><li class=\"choice-50 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_50\" name=\"wpforms[fields][48][]\" value=\"Confusion\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_50\">Confusion<\/label><\/li><li class=\"choice-49 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_49\" name=\"wpforms[fields][48][]\" value=\"Constipation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_49\">Constipation<\/label><\/li><li class=\"choice-48 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_48\" name=\"wpforms[fields][48][]\" value=\"Diarrhea\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_48\">Diarrhea<\/label><\/li><li class=\"choice-47 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_47\" name=\"wpforms[fields][48][]\" value=\"Dysphagia\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_47\">Dysphagia<\/label><\/li><li class=\"choice-46 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_46\" name=\"wpforms[fields][48][]\" value=\"Eye and vision problems\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_46\">Eye and vision problems<\/label><\/li><li class=\"choice-45 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_45\" name=\"wpforms[fields][48][]\" value=\"Fatigue\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_45\">Fatigue<\/label><\/li><li class=\"choice-44 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_44\" name=\"wpforms[fields][48][]\" value=\"Gastritis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_44\">Gastritis<\/label><\/li><li class=\"choice-43 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_43\" name=\"wpforms[fields][48][]\" value=\"Hair loss\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_43\">Hair loss<\/label><\/li><li class=\"choice-42 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_42\" name=\"wpforms[fields][48][]\" value=\"Headaches\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_42\">Headaches<\/label><\/li><li class=\"choice-41 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_41\" name=\"wpforms[fields][48][]\" value=\"Heart attack\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_41\">Heart attack<\/label><\/li><li class=\"choice-40 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_40\" name=\"wpforms[fields][48][]\" value=\"Hearing problems\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_40\">Hearing problems<\/label><\/li><li class=\"choice-39 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_39\" name=\"wpforms[fields][48][]\" value=\"Heightened awareness of pulse in neck\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_39\">Heightened awareness of pulse in neck<\/label><\/li><li class=\"choice-38 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_38\" name=\"wpforms[fields][48][]\" value=\"Hives\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_38\">Hives<\/label><\/li><li class=\"choice-37 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_37\" name=\"wpforms[fields][48][]\" value=\"Hyperhidrosis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_37\">Hyperhidrosis<\/label><\/li><li class=\"choice-36 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_36\" name=\"wpforms[fields][48][]\" value=\"Immune system: Low white blood cells\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_36\">Immune system: Low white blood cells<\/label><\/li><li class=\"choice-35 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_35\" name=\"wpforms[fields][48][]\" value=\"Loss of Consciousness\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_35\">Loss of Consciousness<\/label><\/li><li class=\"choice-34 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_34\" name=\"wpforms[fields][48][]\" value=\"Loss of immunity\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_34\">Loss of immunity<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_33\" name=\"wpforms[fields][48][]\" value=\"Loss of vision\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_33\">Loss of vision<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_32\" name=\"wpforms[fields][48][]\" value=\"Low platelets\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_32\">Low platelets<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_31\" name=\"wpforms[fields][48][]\" value=\"Menstrual changes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_31\">Menstrual changes<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_30\" name=\"wpforms[fields][48][]\" value=\"Miscarriage or still birth\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_30\">Miscarriage or still birth<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_29\" name=\"wpforms[fields][48][]\" value=\"Musculoskeletal disorders\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_29\">Musculoskeletal disorders<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_28\" name=\"wpforms[fields][48][]\" value=\"Myocarditis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_28\">Myocarditis<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_27\" name=\"wpforms[fields][48][]\" value=\"Neurological changes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_27\">Neurological changes<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_26\" name=\"wpforms[fields][48][]\" value=\"Neuralgia\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_26\">Neuralgia<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_25\" name=\"wpforms[fields][48][]\" value=\"Pain\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_25\">Pain<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_24\" name=\"wpforms[fields][48][]\" value=\"Heart Palpitations\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_24\">Heart Palpitations<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_23\" name=\"wpforms[fields][48][]\" value=\"Panic attacks\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_23\">Panic attacks<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_22\" name=\"wpforms[fields][48][]\" value=\"Pericarditis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_22\">Pericarditis<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_21\" name=\"wpforms[fields][48][]\" value=\"Physical disability\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_21\">Physical disability<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_20\" name=\"wpforms[fields][48][]\" value=\"Pneumonia\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_20\">Pneumonia<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_19\" name=\"wpforms[fields][48][]\" value=\"Postural orthostatic tachycardia syndrome (POTS)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_19\">Postural orthostatic tachycardia syndrome (POTS)<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_18\" name=\"wpforms[fields][48][]\" value=\"Priapism\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_18\">Priapism<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_17\" name=\"wpforms[fields][48][]\" value=\"Raynaud&#039;s Syndrome\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_17\">Raynaud's Syndrome<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_16\" name=\"wpforms[fields][48][]\" value=\"Sexual dysfunction\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_16\">Sexual dysfunction<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_15\" name=\"wpforms[fields][48][]\" value=\"Shingles\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_15\">Shingles<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_14\" name=\"wpforms[fields][48][]\" value=\"Skin disease\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_14\">Skin disease<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_13\" name=\"wpforms[fields][48][]\" value=\"Skin rash\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_13\">Skin rash<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_12\" name=\"wpforms[fields][48][]\" value=\"Speech and swallowing problems\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_12\">Speech and swallowing problems<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_11\" name=\"wpforms[fields][48][]\" value=\"Stroke\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_11\">Stroke<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_10\" name=\"wpforms[fields][48][]\" value=\"Suicidal Ideation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_10\">Suicidal Ideation<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_9\" name=\"wpforms[fields][48][]\" value=\"Toxic shock\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_9\">Toxic shock<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_8\" name=\"wpforms[fields][48][]\" value=\"Transverse Myelitis\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_8\">Transverse Myelitis<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_48_7\" name=\"wpforms[fields][48][]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_48_7\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_49-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_49\">Vaccine Symptoms and Conditions - Continue - Please list any other not listed above<\/label><textarea id=\"wpforms-53-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" ><\/textarea><\/div><div id=\"wpforms-53-field_31-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_31\">What treatment did you undergo as a result of the reaction? Medication \/ Hospitalization?<\/label><textarea id=\"wpforms-53-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" ><\/textarea><\/div><div id=\"wpforms-53-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"50\"><label class=\"wpforms-field-label\">What has been the ongoing outcome of the Reaction? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_50\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Death\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_1\">Death<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_2\" name=\"wpforms[fields][50][]\" value=\"Amputations\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_2\">Amputations<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_3\" name=\"wpforms[fields][50][]\" value=\"Hysterectomy\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_3\">Hysterectomy<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_16\" name=\"wpforms[fields][50][]\" value=\"Hospitalised\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_16\">Hospitalised<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_15\" name=\"wpforms[fields][50][]\" value=\"Unable to work\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_15\">Unable to work<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_14\" name=\"wpforms[fields][50][]\" value=\"Intensive care unit\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_14\">Intensive care unit<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_13\" name=\"wpforms[fields][50][]\" value=\"Intubation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_13\">Intubation<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_12\" name=\"wpforms[fields][50][]\" value=\"Outpatient\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_12\">Outpatient<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_11\" name=\"wpforms[fields][50][]\" value=\"Time off work\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_11\">Time off work<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_10\" name=\"wpforms[fields][50][]\" value=\"Need for permanent care\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_10\">Need for permanent care<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_9\" name=\"wpforms[fields][50][]\" value=\"Improving\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_9\">Improving<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_8\" name=\"wpforms[fields][50][]\" value=\"Full recovery\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_8\">Full recovery<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_50_7\" name=\"wpforms[fields][50][]\" value=\"Other - Please give details below\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_50_7\">Other - Please give details below<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_35-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_35\">Ongoing outcome - Please provide as much details as possible<\/label><textarea id=\"wpforms-53-field_35\" class=\"wpforms-field-large\" name=\"wpforms[fields][35]\" ><\/textarea><\/div><div id=\"wpforms-53-field_37-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_37\">Since taking the vaccine, how has this impacted your life? <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-53-field_37\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][37]\" required><\/textarea><\/div><div id=\"wpforms-53-field_51-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"51\"><label class=\"wpforms-field-label\">Do you think you are entitled to compensation?  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_51\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_51_1\" name=\"wpforms[fields][51][]\" value=\"Compensation is needed\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_51_1\">Compensation is needed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_51_2\" name=\"wpforms[fields][51][]\" value=\"Already taking action\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_51_2\">Already taking action<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_51_3\" name=\"wpforms[fields][51][]\" value=\"Willing to join a class action\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_51_3\">Willing to join a class action<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_51_12\" name=\"wpforms[fields][51][]\" value=\"I have filed with the Health website compensation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_51_12\">I have filed with the Health website compensation<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_51_11\" name=\"wpforms[fields][51][]\" value=\"Yes, but unsure what to do\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_51_11\">Yes, but unsure what to do<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_52-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"52\"><label class=\"wpforms-field-label\">Your attitude towards vaccines now <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-53-field_52\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_52_1\" name=\"wpforms[fields][52][]\" value=\"I would accept another vaccination or booster if had too\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_52_1\">I would accept another vaccination or booster if had too<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_52_2\" name=\"wpforms[fields][52][]\" value=\"I would not accept another vaccination\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_52_2\">I would not accept another vaccination<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_52_3\" name=\"wpforms[fields][52][]\" value=\"I encourage friends to be vaccinated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_52_3\">I encourage friends to be vaccinated<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_52_11\" name=\"wpforms[fields][52][]\" value=\"I will discourage friends and family from getting vaccinated\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_52_11\">I will discourage friends and family from getting vaccinated<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_52_10\" name=\"wpforms[fields][52][]\" value=\"The vaccination program needs to stop\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_52_10\">The vaccination program needs to stop<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-53-field_52_9\" name=\"wpforms[fields][52][]\" value=\"Unsure at the moment\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-53-field_52_9\">Unsure at the moment<\/label><\/li><\/ul><\/div><div id=\"wpforms-53-field_43-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-53-field_43\">I would like to thank you for taking the time to fill out this form. If there is anything more you would like to add, please fill out below.<\/label><textarea id=\"wpforms-53-field_43\" class=\"wpforms-field-large\" name=\"wpforms[fields][43]\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"53\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/pages\/56\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-53\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/www.knightsofthecradle.com\/news\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"boldgrid-section\">\n<div class=\"container\">\n<div class=\"row\">\n<div class=\"col-md-12 col-xs-12 col-sm-12\">\n<p>&nbsp;<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Reporting a Vaccine Injury \/ Adverse Reaction Adverse Reaction \/ Injury Form Knights of the Cradle (Yort Knight) have set up a reporting system, relying on people to send in reports of their experience when taking a vaccine and the reactions \/ actions that occurred after. Anyone can fill out<span class=\"more-link\"><a href=\"http:\/\/www.knightsofthecradle.com\/news\/adverse-reaction-registry\/\">Continue Reading<\/a><\/span><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template\/page\/fullwidth.php","meta":{"bgseo_title":"","bgseo_description":"","bgseo_robots_index":"index","bgseo_robots_follow":"follow","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["entry","author-knightsofthecradle_l0a8uw","post-56","page","type-page","status-publish"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/pages\/56","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/comments?post=56"}],"version-history":[{"count":7,"href":"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/pages\/56\/revisions"}],"predecessor-version":[{"id":73,"href":"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/pages\/56\/revisions\/73"}],"wp:attachment":[{"href":"http:\/\/www.knightsofthecradle.com\/news\/wp-json\/wp\/v2\/media?parent=56"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}