Form for Employees Whose Employers Are Requiring Covid-19 Injections

All over America, employees are facing a very tough decision right now. Although some wish to accept a Covid-19 injection, many do not. The problem is that a growing number of employers are trying to deny employees’ right to choose and their right to bodily integrity by requiring the vaccines as a condition of employment. In the United States and other jurisdictions, that is a violation of the law. It is also a violation of fundamental human and religious rights.

In the U.S., the provisions of the 2005 Public Readiness and Emergency Preparedness (PREP) Act and a February 2020 declaration by the Secretary of the Department of Health and Human Services (HHS) mean that pharmaceutical companies cannot be held liable for injuries or deaths caused by the Covid-19 injections.1 However, other companies, institutions, and individuals can be held liable. This form is designed as a tool that employees can use to provide this critical information to employers, and to insist on a signature from the employer’s representative that holds the company liable if the employee should decide to accept the required experimental Covid-19 injection.

We are already seeing that health care providers are refusing service to individuals injured by the Covid-19 injections, and health and life insurance companies are declining coverage for vaccine-related injuries and deaths on the grounds that the injections are investigational vaccines allowed under Food and Drug Administration (FDA) emergency use authorization (EUA) but not otherwise approved or licensed.2This denial of care and coverage poses a serious threat to the physical and financial well-being of employees presented with a requirement to get a Covid injection—perhaps even more so than the possibility of losing their job for not being vaccinated.

Reviewing this form with employers may open their eyes to the regulations in place and the liability they may face (that they may otherwise not be aware of). Everyone should consider reviewing the form with their employer as well as sharing it with co-workers. This could result in a positive impact for employees and could be a game-changer. Alternatively, if the employer representative refuses to sign the form, that may be an indicator of their concern about potential liability and should prompt an immediate discussion about how the employee can continue working for the company without being injected.

If you find yourself in a predicament with a company that refuses to hear you out, does not provide you with required information, or threatens termination of your employment, here are a few potential resources for contacting attorneys. America’s Frontline Doctors provides an intake form on their site that you can fill out and submit, and they will search for an attorney in your area who is taking on this type of case.3 There is a small fee for the search, and of course, attorneys have their own fees. The legal team of the Informed Consent Action Network (ICAN) is offering to assist employees/students who are being required by an employer/school to receive the Covid-19 injection.4 If you find yourself needing a vaccine injury case attorney, you might also try looking through this state list.5

This form was written by Corey Lynn of Corey’s Digs for The Solari Report.

Click here to download the employee form in PDF format. Please note that two other forms are available as downloadable PDFs: the Family Financial Disclosure Form,6 and the Form for Students Attending Colleges or Universities Requiring Covid-19 Injections.7

NOTE TO EMPLOYEE: Be sure to document the date and time you submit this form to your employer; also document the date and time and their response if they refuse to sign it.

NOTE TO EMPLOYER: As your employee, I am requesting that you review this document, provide the requisite information, and sign the form, in regards to your requirement that employees get a Covid-19 emergency use authorization (EUA) investigational vaccine.

1) If I agree to receive an EUA Covid-19 injection, does my employee health insurance plan provide complete coverage should I experience an adverse event, or even death?




2) As an employee, does my life insurance policy provide any coverage in the event that I die from receiving an EUA Covid-19 injection?




3) As an employer, will you be providing Workers’ Compensation, disability insurance, or other resources if I have an adverse event to an EUA Covid-19 injection and am unable to come to work for days, weeks, or months, or if I am disabled for life?




4) The Food and Drug Administration (FDA) requires that EUA vaccine recipients be provided with certain vaccine-specific information to help them make an informed decision about vaccination.8 The EUA fact sheets that must be provided are specific to each authorized Covid-19 injection and are developed by the manufacturers of the injections (Pfizer/BioNTech, Moderna, Oxford/AstraZeneca, and the Johnson & Johnson subsidiary Janssen). The fact sheets must provide the most current and up-to-date information on the injections, and vaccine recipients must also receive information about adverse events. Have you read, understood, and provided me (and all other employees) with these fact sheets and with current information on adverse events so that I/we can make an educated decision?



5) Have you reviewed the available databases of material adverse events reported to date for people who have received Covid-19 injections?9,10,11,12 Potential and reported adverse events include death, anaphylaxis, neurological disorders, autoimmune disorders, other long-term chronic diseases, blindness and deafness, infertility, fetal damage, miscarriage, and stillbirth.



6) The FDA’s guidance13 on emergency use authorization of medical products requires the FDA to “ensure that recipients are informed to the extent practicable given the applicable circumstances…[t]hat they have the option to accept or refuse the EUA product….” Are you aware of this statement? Have you informed all employees that they have the option to refuse?



7) With respect to the emergency use of an unapproved product, the Federal Food, Drug and Cosmetic Act, Title 21 U.S.C. 360bbb-3(e)(1)(A)(ii)(I-III)14 reiterates that individuals be informed of “the option to accept or refuse administration of the product, [and] of the consequences, if any, of refusing administration of the product, and of the alternatives to the product that are available and of their benefits and risks.” If EUA Covid-19 investigational vaccines are ever approved by the FDA, state legislation would be required to allow companies to mandate the Covid-19 injections. Are you aware of these facts?



8) EUA products are unapproved, unlicensed, and experimental. Under the Nuremberg Code—the foundation of ethical medicine—no one may be coerced to participate in a medical experiment. The individual’s consent is absolutely essential. No court has ever upheld a mandate for an EUA vaccine. In Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003)15, a federal court held that the U.S. military could not mandate EUA vaccines for soldiers: “…[T]he United States cannot demand that members of the armed forces also serve as guinea pigs for experimental drugs” (Id. at 135). Are you aware of this?


9) The United States Code of Federal Regulations16and the FDA require the informed consent of human subjects for medical research. The EUA Covid-19 injections are unapproved, unlicensed, investigational vaccines that are still in their experimental stage. It is unlawful to conduct medical research on a human being, even in the event of an emergency, unless steps are taken to secure the informed consent of all participants. Are you aware of this?


10) According to Federal Trade Commission (FTC) Guidelines17and the FTC’s “Truth In Advertising,”18 promotional material—and especially material involving health-related products—cannot mislead consumers, omit important information, or express claims. All of this falls under the rubric of “deceptive advertising” (whereby a company is providing or endorsing a product), whether presented in the form of an ad, on a website, through email, on a poster, or in the mail. For example, statements such as “all employees are required to get the Covid-19 vaccine to make the workspace safe” or “it’s safe and effective” leave out critical information. Critical information includes the facts that Covid-19 injections are unapproved EUA vaccines that “may” or “may not” prevent Covid, won’t necessarily make the workspace safer, and could in fact cause harm. Not providing links or attachments of the manufacturers’ fact sheets and current information on adverse events is omitting safety information. Are you aware of this?


11) Since the Covid lockdowns began over one year ago, there have been over 178 reported breaches of unsecured protected health information (PHI), incidents investigated by the Office for Civil Rights (OCR). These breaches exposed millions of people’s personal health information. Although many of these incidents were attributed to hacking, some of the breaches to PHI fell directly under the 1996 Health Insurance Portability and Accountability Act (HIPAA), such as sharing a patient’s or person’s information with an unauthorized individual or incorrectly handling PHI.19 Can you please explain your obligations to me, under HIPAA law, and how you are going to protect my personal information – both with respect to your requirement that I receive this injection?





12) Whereas pharmaceutical companies that manufacture EUA vaccines have been protected from liability related to injuries or deaths caused by experimental agents since the PREP Act1was enacted in 2005, companies and all other institutions or individuals who mandate experimental vaccines on any human being are not protected from liability. Are you aware that you do not enjoy such liability protection?


13) Are you aware that employees could file a civil suit against you should they suffer an adverse event, death, or termination from their place of employment?



As the legally authorized officer of the employer/company, I have read all of the above information, have provided my employees with all of the information that the FDA requires be provided to recipients of the Covid-19 injections, and do hereby agree to assume 100% financial responsibility for covering any and all expenses from adverse events, including death, through insurance coverage or directly. In addition, I affirm that the employee will not be subjected to the loss of their job should they decline to receive a Covid-19 injection.


  1. Congressional Research Service. The PREP Act and COVID-19: Limiting Liability for Medical Countermeasures. Updated Mar. 19, 2021.
  2. Del Bigtree interviews 3 medical professionals incapacitated by Covid injections. The Highwire, Apr. 29, 2021.
  3. America’s Frontline Doctors. Vaccines & the law.
  4. Layton, Catharine. Forced to get the COVID vaccine? ICAN may be able to help. The Defender, Jan. 29, 2021.
  6. The Solari Report. Family Financial Disclosure Form for Covid-19 injections. Mar. 1, 2021.
  7. The Solari Report. Form for Students Attending Colleges or Universities Requiring Covid-19 Injections. May 3, 2021.
  8. Centers for Disease Control and Prevention. COVID-19 Vaccine Emergency Use Authorization (EUA) Fact Sheets for Recipients and Caregivers.
  9. UK Medical Freedom Alliance. COVID-19 Vaccine Info.
  10. Vaccine Adverse Event Reporting System.
  11. CDC WONDER. About the Vaccine Adverse Event Reporting System (VAERS).
  12. National Vaccine Information Center. Search the U.S. Government’s VAERS Data.
  13. U.S. Department of Health and Human Services. Emergency Use Authorization of Medical Products and Related Authorities: Guidance for Industry and Other Stakeholders. January 2017.
  14. 21 U.S. Code § 360bbb–3 – Authorization for medical products for use in emergencies.
  15. Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003).
  17. Federal Trade Commission. Advertising FAQ’s: A Guide for Small Business.
  18. Federal Trade Commission. Truth in Advertising.
  19. U.S. Department of Health and Human Services. Office for Civil Rights. Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information.;jsessionid=618E88DD94EE65D46D5785CB2A643553.
  21. htps://

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Corey Lynn is an investigative journalist. Support her work by becoming a Patron or making a donation. Follow her at, on Gab, GabTV, and YouTube.


  • Nikki

    Thank you for compiling this information. I work for the University of Illinois and they will require employees to become vaccinated prior to returning to campus in August. I have a preexisting gut condition and after having emergency surgery, I had a complete relapse of my GI tract because of receiving IV medications and antibiotics. Followup testing proved my relapse was due to the meds I was given during that procedure. The last thing I want to do is inflict more experimental chemicals into my body while I’m treating a problem with natural medicines. I did not know what I could do or where to start to even look for help. This has given me hope that I can continue to work and not receive the vaccine. Thank you!

  • Michael l Javick

    Sorry, But this IS A COMPLETE WASTE OF TIME…NO company will sign it. Amerika has been destroyed… You have no clue what is coming next…hint..there will NOT be enough left alive to BURY THE DEAD !

  • Miriam

    This is most interesting. However, what is missing in my POV, is the lawful standing of ANY MAN or WOMAN in the role as a CEO to have the audacity to even command medical intervention without having to give reason or explanation why or how the company was impacted by corona. There are no studies, no clinical trials, there was no mass-extinction of personnel to be witnessed by ANY of these employers. So, ANY law that prohibits trespass of a man or woman by another man or woman by way of extortion is still in place and in full effect. So, ANY authority a man/a woman as an employer has is restricted to health protection directly in proportion to the actual work. Having a flu, a frenzy media and some lunatic colluding politicians CLAIMING a catastrophe day in day out that simply was and is NOT visible IN ANY COMPANY (except for the missing personal due to stupid quarantine) and mandating a physical medical intervention from other men and women or they lose a job is simply criminal extortion. THAT is what men and women who sometimes act as employers should be held accountable for PRIVATELY. Medical interventions are NON of their business. HIIPA law or not. A man forcing another man to do a medical intervention against his will IS de facto unacceptable. And as of now there is NO LAW IN THE WORLD, that could even make it possible, as all superior law is still in effect that prohibits that.
    Employers! You cross the line with this.

  • Laura Rasgorshek

    Hi, Corey,

    Thank you for all of your great investigational reporting! What happens once the vaccines receive full FDA approval? I recently read that Pfizer and Moderna will both soon be filing for full approval. Once they receive full FDA approval, do we have any legal grounds against an employer or school requiring the vaccine?


  • DE Prata

    This document doesn’t have any legal standing. Most employers have “at-will” contracts and can terminate employees for any reason without repercussions. Most of the questions, “are you aware of this?” can be answered yes and will have zero effect legally. Get a good lawyer that can reword this document that shows that the vaccine goes against the existing employment contract and file a cease and desist motion in court. You still may get terminated for “insubordination” or some other minor issue. Threaten legal action at the hint of forced inoculations.

  • Jesse

    There’s a glaring problem here; the elephant in the room.

    What compensation should be entitled to if you for losing your job AFTER making a life altering decision like receiving a blood injection?

  • Dipak

    Very useful application and information. Every people of world should thanks to Carrie made and teem who prepared this draft.
    Vaccination is a way to to hell. 🙏

  • Janice Mcshane

    Do you have a forms for for schools such as colleges? My son transferred to a college in January. In order to attend in the fall they want him to get a Covid-19 vaccine. He asked if he could go online but was told he had to switch majors. So he switched to another college for the fall semester. After all the paper work was finished the new college came out today stating they are also requiring fall students to get this experimental vaccine.

  • Jennifer Purdon

    Unfortunately this is so long no one in my HR department will take the time to read it. They’re all flaming liberals drinking the kovid koolaid and have already been vaxxed. It’s just a matter of time before they force us to do it. I too would like to see one of these, but much shorter, to use with businesses I.e. airlines. Thanks Corey!

  • Still Learning

    I don’t know if anyone has mentioned this yet but i think there is a typo:

    “3) As an employee”

    Shouldn’t that read “employer” as the employer is the one that needs to answer the question?

    I have not read past this point bc i was afraid I’d get busy and forget to say anything, but I’m sure it’s otherwise excellent work, as always, Corey!

    I’ve been a patron for a while now and you Never disappoint!

    May GOD continue to keep you in His strength and wisdom for you to fulfill His calling in this good work. In the Mighty Name of our Salvation, Jesus, The Christ!


    Still Learning

  • Mike

    Thank you, Corey!

    As a vendor to certain public academic institutions, I am concerned that my clients may demand injections of myself and my crew.

    Can you please create a document that adjusts language to address small business concerns as vendors to large institutions sympathetic to the injections?

    Thank you so much!

  • CH

    “COVID-19 injections”? Oh are you kidding? I do NOT want to received an injection of the disease. 🤣🤣🤣

  • Alice Smith

    MICHAEL L JAVICK, you wrote: “Sorry, But this IS A COMPLETE WASTE OF TIME…NO company will sign it.”

    Of course, no company will sign it. That’s the point. If they refuse to sign it, they have no right to ask you to take the shot. This is one awesome document to hand to an employer. It’s worth it’s weight in gold and may very well save lives.

  • John Faber

    Since this injection in NO way complies with the definition of a “vaccine”, it seems that an informed document should not refer to the injection as such. In fact, that might be a good paragraph to add to the document!!

  • Feber James

    So was this written by a teenager? It’s definitely not written by anyone who has a clue about writing contracts (or any other kind of agreement).

  • anarchyst

    Obtain a fake CDC COVID-19 vaccination certificate and fill it out yourself. These can easily be created on card stock which mimics the “real” thing.

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