Form for Employees and Students Whose Employers and schools Are Requiring Covid-19 Injections

Form for Employees and Students Whose Employers and schools Are Requiring Covid-19 Injections
Prepare For Change / Edward Morgan

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.


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