Form for Employers and Companies (Clients) who hire Independent Contractors Requiring Covid-19 Injections
NOTE TO Employers and Companies (Clients) who hire Independent Contractors:
As an employee or independent contractor for your company I am requesting that you review
this document, provide the requisite information, and sign the form, in regards to your requirement
that employees and independent contractors get a Covid-19 emergency use authorization (EUA) experimental vaccine for work and law of agency purposes.
1) If I agree to receive an EUA Covid-19 injection, does my health insurance plan [if
applicable] provide complete coverage should I experience an adverse event, or even death?
2) As an employee or independent contractor for your company will you provide any other medical or financial support to me (Workman’s Compensation for employee status) or my family if I have an adverse event to an EUA Covid-19 injection and am unable to do business or work as an employee days, weeks, or months, or if I am disabled for life?
3) The Food and Drug Administration (FDA) requires that EUA vaccine recipients be provided with
certain vaccine-specific information to help them make an informed decision about vaccination.
The EUA fact sheets that must be provided are specific to each authorized Covid-19 injection and are developed by the manufacturers of the injections (Pfzer/BioNTech, Moderna, Oxford/AstraZeneca, and the Johnson & Johnson subsidiary Janssen). The fact sheets must provide the most current and up-to-date information on the injections, and vaccine recipients must also receive informatory about adverse events. Have you read, understood, and provided me (and all other employees and contractors you do business with) with these fact sheets and with current information on adverse events so that I/we can make an educated decision?
4) Have you reviewed the available databases of material adverse events reported to date for
people who have received experimental Covid-19 injections? 10,11,12,13 Potential and reported adverse events include death, anaphylaxis, neurological disorders, autoimmune disorders, other long-term chronic diseases, blindness and deafness, infertility, fetal damage, miscarriage, and stillbirth.
5) The FDA’s guidance 14 on emergency use authorization of medical products requires the FDA to
“ensure that recipients are informed to the extent practicable given the applicable circumstances...
[t]hat they have the option to accept or refuse the EUA product....” Are you aware of this statement?
Have you informed all employees and contractors you do business with that they have the option to refuse?
6) With respect to the emergency use of an unapproved product, the Federal Food, Drug and
Cosmetic Act, Title 21 U.S.C. 360bbb-3(e)(1)(A)(ii)(I-III) 15 reiterates that individuals be informed of “the option to accept or refuse administration of the product, [and] of the consequences, if any, of
refusing administration of the product, and of the alternatives to the product that are available and of their benefits and risks.” If experimental EUA Covid-19 vaccines are ever approved by the FDA, state legislation would be required to allow companies to mandate the Covid-19 injections. Are you aware of these facts?
7) EUA products are unapproved, unlicensed, and experimental. Under the Nuremberg Code—the
foundation of ethical medicine—no one may be coerced to participate in a medical experiment. The
individual’s consent is absolutely essential. No court has ever upheld a mandate for an EUA vaccine. In Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003), 16 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 armed forces also serve as guinea pigs for experimental drugs” (Id. at 135). Are you aware of this?
8) The United States Code of Federal Regulations 17 and the FDA require the informed consent of
human subjects for medical research. The EUA Covid-19 injections are unapproved, unlicensed,
investigatory vaccines that are still 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 participants. Are you aware of this?
9) According to Federal Trade Commission (FTC) Guidelines 18 and the FTC’s “Truth In Advertising,” 19 promotional material—and especially material involving health-related products—cannot mislead consumers, omit important information, or express claims. All of this falls under the rubric of “deceptive advertising” (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 or independent contractors contracted do to business are required to get the Covid-19 vaccine to make the business or workplace safe” or “it’s safe and effective” leave out critical information. Critical information includes the facts that Covid-19 injections are unapproved EUA vaccines that “may” or “may not” prevent Covid, won’t necessarily
make bossinesses and workplaces safer, and could in fact cause harm. Not providing links or attachments of the manufacturers’ fact sheets and current information on adverse events is omitting safety information. Are you aware of this?
10) Since the Covid lockdowns began over one year ago, there have been over 178 reported breaches of unsecured protected health information (PHI), incidents investigated by the Office for Civil Rights (OCR). These breaches exposed millions of people’s personal health information. Although many of these incidents were attributed 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 information with an unauthorized individual or incorrectly handling PHI. 20 Can you please explain your obligations to me, under HIPAA law, and how you are going to protect my personal information - both with respect to your requirement that I receive this injection?
11) Whereas pharmaceutical companies that manufacture EUA vaccines have been protected from
liability related to injuries or deaths caused by experimental agents since the PREP Act 2 was enacted in 2005, companies, schools, and all other institutions 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 protection?
12) Are you aware that families or students or employees or independent contractors could file a civil suit against you should the employee, student or independent contractor suffer an adverse event, death, or expulsion from school for refusing an EUA Covid-19 injection?
As the legally authorized officer of the college or university, or the legally authorized employer or legal owner of business, whether hiring out independent contractors or paying their employers salaries, I have read all of the above information, have provided my employees, students or those I hire as independent contractors with all of the information that the FDA requires be provided to recipients of the Covid-19 injections, and do hereby agree to assume 100% financial responsibility for covering any and all expenses from adverse events, including death, through insurance coverage or directly. In addition, I affirm that the student, employee or independent contractor shall not be denied access to work or school should they decline to receive a Covid-19 injection.
Authorized officer of college/university, or legal owner/employer of company requiring injection:
College/University or business concerned:
Date:____________________ Student:___________________ Employee: ____________________
Independent Contractor Signature: ____________________________________________________
Independent Contractor LLC name: ___________________________________________________
Witness signature: ________________________________________________________________
Associaton of American Physicians and Surgeons. Open letter from physicians to universities: allow students back without COVID vaccine mandate. AAPS, Apr. 24, 2021. https://aapsonline.org/open-leter-from-physicians-to-universites-reverse-covid-vaccine-mandates/.
Congressional Research Service. The PREP Act and COVID-19: Limitng Liability for Medical Countermeasures. Updated Mar. 19, 2021. https://crsreports.congress.gov/product/pdf/LSB/LSB10443.
Del Bigtree interviews 3 medical professionals incapacitated by Covid injectons. The Highwire, Apr. 29, 2021. https://www.bitchute.com/video/A4d8FB2cIBTc/.
America’s Frontline Doctors. Vaccines & the law. https://www.americasfrontlinedoctors.org/legal/vaccines-the-law.
Catharine Layton. Forced to get the COVID vaccine? ICAN may be able to help. The Defender, Jan. 29, 2021.
Catharine Layton. Forced to get the COVID vaccine? ICAN may be able to help. The Defender, Jan. 29, 2021.
The Solari Report. Family Financial Disclosure Form for Covid-19 injectons. Mar. 1, 2021. https://pandemic.solari.com/family- fnancial-disclosure-form-for-covid-19-injectons/.
Centers for Disease Control and Preventon. COVID-19 Vaccine Emergency Use Authorizaton (EUA) Fact Sheets for Recipients
and Caregivers. https://www.cdc.gov/vaccines/covid-19/eua/index.html.
UK Medical Freedom Alliance. COVID-19 Vaccine Info. https://www.ukmedfreedom.org/resources/covid-19-vaccine-info.
Vaccine Adverse Event Reportng System. https://vaers.hhs.gov.
CDC WONDER. About the Vaccine Adverse Event Reportng System (VAERS). https://wonder.cdc.gov/vaers.html.
Natonal Vaccine Informaton Center. Search the U.S. Government’s VAERS Data. https://www.medalerts.org/.
U.S. Department of Health and Human Services. Emergency Use Authorization of Medical Products and Related Authorities: Guidance for Industry and Other Stakeholders. January 2017. https://www.fda.gov/media/97321/download.
21 U.S. Code § 360bbb–3 - Authorizaton for medical products for use in emergencies.
Doe #1 v. Rumsfeld, 297 F. Supp. 2d 119 (2003). https://www.courtlistener.com/opinion/2326816/doe-v-rumsfeld/.
Federal Trade Commission. Advertsing FAQ’s: A Guide for Small Business. https://www.fc.gov/tps-advice/business-center/guidance/advertsing-faqs-guide-small-business.
Federal Trade Commission. Truth in Advertising. https://www.fc.gov/news-events/media-resources/truth-advertising.
U.S. Department of Health and Human Services. Ofce for Civil Rights. Breach Portal: Notice to the Secretary of HHS Breach of Unsecured Protected Health Information.