AFLDS Kaiser Constituent Form

AFLDS Kaiser Constituent Form

AFLDS is looking for Kaiser employees or workers whose job wants to force them to take the Covid-19 vaccine. Please fill out this form (there are no “right” answers so please be accurate!!) if you are even THINKING about legal action! Even if you have chosen to be vaccinated, if you don’t want to live in a country where your employer can do such things, please fill out the form. If your information matches our criteria, our legal team will get in touch with you. You can share this link with other Kaiser workers: https://americasfrontlinedoctors.org/kaiser/
Name*

First NameLast Name
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*
If you have a “home” address that is in-state, please use that address.
City*
State*
ZIP Code*
County*
Select State of your Job*
Do you interact with patients? (Work in a clinical setting.)*

YesNo
Do you work 100% remotely?*

YesNo
Which Kaiser Permanente entity do you work for?*
Job category:*
Specialty:*
Job level:*
Job schedule: *
Are you a member of a Union or Employee Group?*

YesNo
If yes, what is your Employee Group/Union Affiliation?
Are you a:*
Do you work for Kaiser or are you an outside vendor or supplier or IC (independent contractor) or similar? For example sales or insurance or similar.*
Approximately, how long have you worked for Kaiser Permanente? *
Please enter the name of your employer as it appears on your paycheck.*
Are you an employee, outside contractor, or vendor?*

EmployeeContractorVendor
If you have an employee handbook please provide the link, or attach the file.

Cancelof
Link to employee handbook (if you have one).
Have you already submitted a religious or medical exemption request to your job?*

YesNo
If yes, have you received a religious or medical exemption?

YesNo
Are you a female under 40?*

YesNo
Do you possibly want to get pregnant in the future?*

YesNo
Have you received any written communication from your union about the mandates of the vaccine?*

YesNoN/A
If yes, briefly describe:
Have you ever had Covid-19?*

YesNo
Evidence of prior Covid-19?*

PCR TestAntibody TestSymptomsN/A
Have you or a family member ever had a bad reaction to a vaccine in the past?

YesNo
Please explain:
Do you have a health issue which you feel puts you at risk for taking the Covid vaccine?

YesNo
Please explain:
I’ve taken the Covid Vaccine and am experiencing adverse reactions or events?

YesNo
Please explain:
You understand that you are submitting personal information related to your health. Your data will NEVER be shared, sold or rented.*

I Understand
Should be Empty: