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Form for Employees Whose Employers Are Requiring Covid-19 Injectons

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

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

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

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

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

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4) The Food and Drug Administraton (FDA) requires that EUA vaccine recipients be provided with

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certain vaccine-specifc informaton to help them make an informed decision about vaccinaton. The EUA fact sheets that must be provided are specifc to each authorized Covid-19 injecton and are

developed by the manufacturers of the injectons (Pfzer/BioNTech, Moderna, Oxford/AstraZeneca, and the Johnson & Johnson subsidiary Janssen). The fact sheets must provide the most current and up-to-date informaton on the injectons, and vaccine recipients must also receive informaton about adverse events. Have you read, understood, and provided me (and all other employees) with these fact sheets and with current informaton on adverse events so that I/we can make an educated decision?

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

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

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

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8) EUA products are unapproved, unlicensed, and experimental. Under the Nuremberg Code—the

foundaton of ethical medicine—no one may be coerced to partcipate in a medical experiment. The

individual’s consent is absolutely essental. No court has ever upheld a mandate for an EUA vaccine. In

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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 Regulatons16 and the FDA require the informed consent of human subjects for medical research. The EUA Covid-19 injectons are unapproved, unlicensed, investgatonal vaccines that are stll 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 partcipants. Are you aware of this?

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10) According to Federal Trade Commission (FTC) Guidelines17 and the FTC’s “Truth In Advertsing,”18 promotonal material—and especially material involving health-related products—cannot mislead consumers, omit important informaton, or express claims. All of this falls under the rubric of “deceptve advertsing” (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 efectve” leave out critcal informaton. Critcal informaton includes the facts that Covid-19 injectons 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 atachments of the manufacturers’ fact sheets and current informaton on adverse events is omitng safety informaton. Are you aware of this?

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11) Since the Covid lockdowns began over one year ago, there have been over 178 reported breaches of unsecured protected health informaton (PHI), incidents investgated by the Ofce for Civil Rights (OCR). These breaches exposed millions of people’s personal health informaton. Although many of these incidents were atributed to hacking, some of the breaches to PHI fell directly under the 1996 Health Insurance Portability and Accountability Act (HIPAA), such as sharing a patent’s or person’s

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, 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

Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003)

informaton with an unauthorized individual or incorrectly handling PHI.

Can you please explain your obligatons to me, under HIPAA law, and how you are going to protect my personal

informaton – both with respect to your requirement that I receive this injecton?

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12) Whereas pharmaceutcal companies that manufacture EUA vaccines have been protected from liability related to injuries or deaths caused by experimental agents since the PREP Act1 was enacted in 2005, companies and all other insttutons 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 protecton?

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

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

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Authorized ofcer of company requiring injecton

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Employee

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Witness

Endnotes:

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Company Date

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Company Date

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Company Date

1. Congressional Research Service. The PREP Act and COVID-19: Limitng Liability for Medical Countermeasures. Updated Mar. 19, 2021. htps://crsreports.congress.gov/product/pdf/LSB/LSB10443.
2. Del Bigtree interviews 3 medical professionals incapacitated by Covid injectons. The Highwire, Apr. 29, 2021.htps://www.bitchute.com/video/A4d8FB2cIBTc/.
3. America’s Frontline Doctors. Vaccines & the law. htps://www.americasfrontlinedoctors.org/legal/vaccines-the-law.
4. Layton, Catharine. Forced to get the COVID vaccine? ICAN may be able to help. The Defender, Jan. 29, 2021.

htps://childrenshealthdefense.org/defender/forced-to-get-covid-vaccine-ican-may-be-able-to-help/ .

5. htps://uscfc.uscourts.gov/sites/default/fles/Vaccine%20Atorneys.pdf.
6. The Solari Report. Family Financial Disclosure Form for Covid-19 injectons. Mar. 1, 2021. htps://pandemic.solari.com/family-

   fnancial-disclosure-form-for-covid-19-injectons/.

7. Corey Lynn, The Solari Report. Form for Students Atending Colleges or Universites Requiring Covid-19 Injectons. May 3,

   2021.

8. Centers for Disease Control and Preventon. COVID-19 Vaccine Emergency Use Authorizaton (EUA) Fact Sheets for Recipients

   and Caregivers. htps://www.cdc.gov/vaccines/covid-19/eua/index.html.

9. UK Medical Freedom Alliance. COVID-19 Vaccine Info. htps://www.ukmedfreedom.org/resources/covid-19-vaccine-info.
10. Vaccine Adverse Event Reportng System. htps://vaers.hhs.gov.
11. CDC WONDER. About the Vaccine Adverse Event Reportng System (VAERS). htps://wonder.cdc.gov/vaers.html.
12. Natonal Vaccine Informaton Center. Search the U.S. Government’s VAERS Data. htps://www.medalerts.org/.
13. U.S. Department of Health and Human Services. Emergency Use Authorizaton of Medical Products and Related Authorites:

    Guidance for Industry and Other Stakeholders. January 2017. htps://www.fda.gov/media/97321/download.

14. 21 U.S. Code § 360bbb–3 – Authorizaton for medical products for use in emergencies.

    htps://www.law.cornell.edu/uscode/text/21/360bbb-3.

15. Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003). htps://www.courtlistener.com/opinion/2326816/doe-v-rumsfeld/.
16. htps://www.govregs.com/regulatons/expand/ttle21_chapterI_part50_subpartB_secton50.24#regulaton_2.
17. Federal Trade Commission. Advertsing FAQ’s: A Guide for Small Business. htps://www.fc.gov/tps-advice/business-

    center/guidance/advertsing-faqs-guide-small-business.

18. Federal Trade Commission. Truth in Advertsing. htps://www.fc.gov/news-events/media-resources/truth-advertsing.
19. U.S.DepartmentofHealthandHumanServices.OfceforCivilRights.BreachPortal:NotcetotheSecretaryofHHSBreachof

    Unsecured Protected Health Informaton.

    htps://ocrportal.hhs.gov/ocr/breach/breach_report.jsf;jsessionid=618E88DD94EE65D46D5785CB2A643553 .

20. .htp://market-tcker.org/akcs-www?post=242282
21. htps://www.natlawreview.com/artcle/osha-s-new-guidance-recordability-covid-19-vaccine-reactons