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Fake Proof of Vaccination
Incident Report
Incident Date/Time
Please describe the incident
Incident Address
Address or Location
Apartment/Unit Number
Was the proof of vaccination shown to you in person or found by you online?
Choose One
In Person
Online
Please provide the website or mobile app where you found the fake proof of vaccination
Did the incident occur at an event, a business, or through contact with an individual?
Choose One
Event
Business
Individual
Event Name
Business Name
Name of Individual
Description of Individual
How was the fake proof of vaccination presented?
Physically (paper)
Electronically (phone or tablet)
Do you have the fake proof of vaccination or copies in your possession?
Choose One
Yes
No
What makes you think the documents are fake?
Is the fake proof of vaccination for sale?
Choose One
Yes
No
Not Sure
Are they being sold by an individual or business?
Choose One
Business
Individual
Name of Individual Selling the Fake Proof of Vaccination
Name of Business Selling the Fake Proof of Vaccination
Your Name
Your Address
Address or Location
Apartment/Unit Number
What is the best way to contact you?
Choose One
Phone
E-mail
Do Not Contact
Your Phone Number
Your E-mail Address
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