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COVID-19 Vaccine Mandate Complaint Form
Use this form to submit a complaint concerning a COVID-19 Vaccine Mandate. The incident must have happened on or after February 6, 2024. 
10-digit phone number (digits only, no spaces, dashes, or parentheses)
Must include: Street, City, State, Zip Code, Country. Only letters, numbers, spaces, and basic punctuation allowed.
Upload supporting documents or images (max 20 MB). Allowed: PDF, Word, text, JPG/PNG/GIF/BMP.
Unlimited number of files can be uploaded to this field.
20 MB limit.
Allowed types: pdf, doc, docx, txt, rtf, jpg, jpeg, png, gif, bmp.
Public Information Act: Information provided in this complaint may be subject to release under the Public Information Act. All documents provided to TWC become part of official agency records upon receipt by TWC. This includes emails and faxes, as well as any information transcribed by TWC staff based on verbal communication with you.

I acknowledge that this constitutes a legal complaint concerning a Covid-19 Vaccine Mandate. For the complaint to be considered valid, the adverse action being reported must have occurred on or after February 6, 2024. By submitting this form, I declare that the information provided is true and correct under penalty of perjury.

My name is , my date of birth is , and my address is . I declare under penalty of perjury that the foregoing is true and correct.

Executed in County, State of Texas, on the 16 day of June, 2026.

Declarant: