AFLDS Form for Workers
AFLDS is looking for federal (or private) workers whose employer wants to force them to take the COVID-19 vaccine. If your employer is located in Louisiana, Texas, or Mississippi, please fill out this form (there are no “right” answers so please be accurate!) and if your information matches our criteria, our legal team will get in touch with you. If your employer’s state is not listed here, please enter your information for potential future cases by using this link: https://americasfrontlinedoctors.org/forms/plaintiff/
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Home City
*
Home State
*
Home Zip Code
*
Home County
*
State of Employer
*
Louisiana
Texas
Mississippi
Name of Employer
*
Is your employer federal of private?
*
federal
private
Has your employer implemented a vaccine policy?
*
Yes
No
Other
Have you already submitted an exemption request to your employer?
*
Yes
No
Please specify type(s) of exemption requests
Are you currently employed
*
Yes
No
Please specify why you are no longer employed
Have you ever had COVID-19 infection?
*
Yes
No
Evidence of prior COVID-19 infection?
*
PCR Test
Antibody Test
Symptoms
N/A
Have you or a family member ever had a bad reaction to ANY vaccine in the past?
*
Yes
No
Do you have a health issue which you believe puts you at risk for takingthe COVID vaccine?
*
Yes
No
Have you experienced adverse reactions or events after taking any dose of a COVID-19 vaccine?
*
Yes
No
Work City
*
Work ZIP
*
Work County
Do you live in?
Please Select
Bronx
Brooklyn
Manhattan
Queens
Staten Island
Do you work in?
Please Select
Bronx
Brooklyn
Manhattan
Queens
Staten Island
Do you own or manage a business in NYC?
Please Select
Bronx
Brooklyn
Manhattan
Queens
Staten Island
Will you be discriminated against if you can’t show proof of vaccination?
*
Yes
No
Please explain:
Please explain:
I’ve taken the Covid Vaccine and am experiencing adverse reactions or events?
Yes
No
Please explain:
You understand that you are submitting personal information related to your health that may be used in legal cases as a plaintiff. Your data will NEVER be shared, sold, or rented
*
I Understand
Submit
Should be Empty: