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Deaths peri-vaccination
Answer for any deaths you ABSOLUTELY know the details of, e.g., a family member or in your medical practice. This form is designed for both doctors and regular people. All deaths count regardless of cause. This is an all-cause mortality survey.

NOTES:

1. Answer just for mRNA vaccines (2 dose primary series)

2. Because dose #1 and dose #2 are 30 days apart, there is NO category for "30 days BEFORE #2" since it is may overlap "30 days after #1".

3. If you have >4 deaths, please fill in the number in the Other field
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Number of people I know who died within 4 weeks **BEFORE** they were planning to get dose 1 of the COVID vaccine
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Number of people I know who died within 4 weeks **AFTER** they got COVID dose 1
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Number of people I know who died within 4 weeks **AFTER** they got COVID dose 2
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Number of people I know who died within 4 weeks **BEFORE** they were planning to get COVID booster #1 (dose 3)
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Number of people I know who died within 4 weeks **AFTER** they got COVID booster #1 (dose 3)
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Number of people I know who died within 4 weeks **BEFORE** they were planning to get Booster #2 (dose 4)
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Number of people I know who died within 4 weeks **AFTER** they got Booster #2 (dose 4)
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