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Children under age 21 who died from the COVID vaccine

Please fill out for any child you know under age 21 who died from the COVID vaccine in any country

Kept private. Needed for verification purposes. You can use a protonmail account for privacy so we cannot find out who you are unless you tell us in the event we need to verify your submission.
OPTIONAL: Kept private. Needed for verification purposes. You can leave this blank if you are concerned about providing this, but it is MUCH easier to verify info if we have this because we can discuss your submission more easily in a call than back and forth via email. I reach out to about 0.04% of people who fill out the survey so it's unlikely you'll be called.
Relationship to the child
What is your relationship to the child who died?
this is important to eliminate duplicate reports
this is important to eliminate duplicate reports
Sex
Please enter the sex of the deceased
Enter a NUMBER between 0 and 20 (no text please).
Country
Where did the death occur?
# COVID shots
How many COVID injections did the child have?
How long after their most recent COVID shot did they die? Leave blank if you don't know. Otherwise enter a number under 1000
Referred by
How did you hear about this survey?
Details...
Why do you think the shots caused the child to die?
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