AFLDS Kentucky Constituent Form

AFLDS Kentucky Constituent Form

AFLDS is looking for Kentucky healthcare 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 workers from your hospitals with vaccine mandates: https://americasfrontlinedoctors.org/kentucky/
Name*

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

YesNo
Do you work remotely?*

YesNo
Are you a:*
Have you already submitted an exemption request to your job?*

YesNoOther
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: