Please fill out as much information as you can. While most fields are optional and the entire form does not to be completed in order to submit your story, the more information you are able to provide, the better we will be able to serve you and advance our mission.
This will be the image that appears on the case folder.
Many victims choose to use the second photo to highlight the suffering the victim endured. It is important to have two different pictures on file for each case. If you cannot provide pictures now, you will have an opportunity to send them to us later.
Please tell us the sex of the victim.
Was the victim receiving Medicare or Medicaid benefits?
Was the victim insured at the time of hospitalization or injury?
If the victim had health insurance, please select your provider from this list. If the insurance provider is not listed, please scroll to the bottom of this list and select "Other" so you can input the insurer below.
Was the victim in the armed forces or police force?
If the victim served in the armed forces, what branch did they serve?
In what state did the incident take place?
Where did the incident take place?
There are many different crimes against humanity taking place right now. Select all that are relevant to the experience you are documenting.
Which mandates played a factor in the victim's decisions that led to their harm or demise? Check all that apply.
Elaborate on how mandates played a role in what happened to the victim.
Please check the box if the victim received any so-called COVID vaccines.
How many "vaccines" and "boosters" were administered to the victim before adverse reactions developed?
How many "vaccines" and "boosters" were administered to the victim, in total?
Was the victim informed that COVID vaccines only have Emergency Use Authorization from the FDA, and are not actually 'FDA approved'?
Was the victim informed of potential COVID-19 vaccine side effects before being given the injection?
Was the victim asked to sign a waiver or consent form in advance of being vaccinated?
If you know the brand of the first COVID vaccine the victim was administered, tell us here.
What brand of COVID vaccine was the victim injected with the second time?
What brand of COVID vaccine was the victim injected with the third time?
What brand of COVID vaccine was the victim injected with the fourth time?
What brand of COVID vaccine was the victim injected with the fifth time?
What brand of COVID vaccine was the victim injected with the sixth time?
What brand of COVID vaccine was the victim injected with the seventh time?
What brand of COVID vaccine was the victim injected with the eighth time?
Please describe all symptoms experienced by the victim.
Tell us about the doctor or doctors involved in this case.
Was the victim admitted to the hospital in relation to this case?
While in the hospital, was the victim allowed to see family or given access to a patient advocate?
Was the victim was asked if they had been vaccinated and/or boosted by doctors or hospital staff?
Does the victim or family feel they were treated differently by hospital staff as a result of disclosing their vaccination status?
If you believe the victim was treated differently by doctors and/or hospital staff after disclosing their vax status, please describe the experience.
Was the victim or the victim's family was asked to sign a Do Not Resuscitate order?
Was the victim deprived of food and water while in the hospital?
What medications were administered to the victim by doctors or hospital staff? Please check all you believe were administered.
What medications did the hospital explicitly refuse to administer to the victim? Please check all you believe were administered.
Was the victim informed that remdesivir has only Emergency Use Authorization from the FDA, and is not actually approved to treat COVID?
Was the victim informed of potential remdesivir side effects before being given the drug?
Did the victim or the family consent to the use of remdesivir?
Was victim was placed on a ventilator?
Has any medical professional given a diagnosis indicating what the victim is suffering from?
What was the victim diagnosed with? Check all that apply, or input your own selections.
Generally, how was the victim treated while at the hospital?
Check all that apply. If you add an item that is not listed, keep it short: a few words or less.
A brief summary of how the victim was treated in the hospital
If there was a cause of death determined by officials, please check all that apply.
What do you think killed the victim, or what does the family believe really killed their loved one?
Medical records can help piece together what happened to the victim. Have you obtained, or do you plan to obtain a complete set of medical records?
Have discrepancies been identified in the medical records?
Is the victim or the family pursuing legal action against the doctor or hospital?
Has the victim or family already retained a lawyer or legal team to help with this case?
Is the victim or the family engaging in any activism as a result of this experience?
What victim or family doing to ensure this doesn't happen to anyone else? What is their advice for other families going through this experience? What do they believe should be done to bring justice to their loved one?
Is there anything else you think the world should know about what happened?
We hold a support group for victims of the FDA Death Protocol and their families, every Monday evening. The group would love it if you would join us and share your story with others who have been through this.
We have a task force seeking justice for victims of the FDA Death Protocol and their families, and pursuing action other issues essential to our liberty. Would you like to join The FFFF Task Force?
Task Force members are organizing a series of podcasts highlighting these crimes against humanity and the assault on medical freedom. Would you be interested in participating in these podcasts?
How did you find this site?
We know it's difficult to go over it all again, but telling your story in your own words is the most powerful way to convey it. Please take your time and tell us as much or as little as you are comfortable with. If you absolutely cannot bring yourself to write it out, one of our volunteers may summarize your story based on the information you have provided and based on your interview. We prefer you tell your story, in as much detail as possible.