miRic Contact Information & Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome to miRic. An Independent Public Interest, Awareness & Empowerment platform on Informed Consent. As a NPC with Public Participation, we have an advisory legal team that provide free legal documents for public use. In line with informed consent, we also work with an advisory medical team. Should you require recommendations on attorneys and/or doctors, we can refer you.

We are committed to protecting your privacy. To best serve you within our network, we collect personal information which will remain confidential. We will however use basic demographic information as statistics, info-graphics, graphs, news etc. to publish data. Information of disclosure / non-disclosure is listed in each Section.

My Individual Right to Informed Consent (miRic), a registered non-profit company whose beneficiaries are different members of society in South Africa. miRic primarily works for the advancement and protection of the constitutional rights of its beneficiaries, especially where medical procedure and/or experimentation is concerned. Where applicable, we take legal action against parties that don't comply to Informed Consent. miRic does so as a stand-alone or with co-applicants of public participation of members of society in South Africa.

Email *

SECTION 1 - Personal & Confidential Information

Protocols of POPIA Guaranteed.

Name *

Surname *

Cell number (Confidential) *

Date of Birth *

YYYY

South African Citizenship *

Citizenship Other (Please indicate below)

SECTION 2 - General demographic information

This section will be used for publications.

Postal Code *

Province *

Age Group *

Gender *

Ethnicity / Race *

Home language *

Official South African languages spoken *

Other languages spoken

Employment status OR Lifestyle status *

Preferred choice for messaging service we may use for communication? *

MOYA (#datafree) - No airtime? No problem! https://moya.app/dl (Android only)

Required

SECTION 3 - covid-19 related data

This section will be used for publications.

Have you been tested for covid-19? *

Have you taken the covid-19 injection *

Any Adverse Effects? *

Have you reported Adverse Event to www.savaers.co.za ?

SECTION 3 - Informed Consent

Your interest in Informed Consent as an *

Purpose of Informed Consent enquiry (you may choose more than 1 item) *

Just in case I may need them

I am being requested to partake, but don't want to

I can assist others to understand they have choices

I want to provide miRic documents to my staff to ensure they have Informed Consent

Since taking the covid-19 injection, I learnt more about Informed Consent

Required

Optional: If you have been presented with documents or correpondence, please provide copies to: contact@miric.co.za - Subject Line: Name Surname Cell Number

miRic Informed Consent document/s are designed to protect you against any request to take part in the covid-19 injection roll-out, mask or pcr. *

Guide to Informed Consent

Education | Liability (Educator, Student, Staff, Parent, Guardian, Proxy etc.)

Employment | Liability (Staff including contract workers, sub-contractors, casual labour etc.)

Elder, Frail or Disabled | Liability (Individual, Group/Church, Resident etc.)

Health Care Authority | Liability

Face Cover or Mask | Liability

pcr or tests

Notice to Defer (Decline)

*(UN)informed Consent (if after the fact of partaking in the covid-19 injection roll-out)

** Not allowed to enter / access without proof of covid-19 injection or negative pcr / other testing

Required

If Other was chosen, please describe.

Free Informed Consent Group Workshop via Zoom or Group Workshop in-person (availability dependent) required? *

Yes, as an Enitity / Facility / Authority.

Yes, as an Individual.

Other:

Required

If Other was chosen, please describe.

General comments or queries on Group Workshops

SECTION 4 Optional - NOMINATE (will be disclosed only if entity authorises)

NOMINATE Entities / Facilities / Authorities / Individuals that don't take part in injection and/or pcr and/or mask covid-19 program.

Nominate Entities / Facilities / Authorities / Individuals / Other that does not partake in the covid-19 injection roll-out. (Entity Name, Contact person, Designation, email, physical address & telephone number. )

SECTION 5 Optional - REPORT (will be disclosed only if entity authorises) or (will not be disclosed in the interim, but will be once in court)

Entities / Facilities / Authorities / Individuals that don't take part in injection and/or pcr and/or mask covid-19 program.

Report Entities / Facilities / Authorities / Individuals / Other that currently take part in, or already has taken part in, or indicating they might/will take part in the covid-19 injection rollout. (Entity Name, Contact person, Designation, email, physical address & telephone number.)

SECTION 6 - In closing

I herewith consent to: 1) processing of my personal information with my confidential information being legally protected within miRic; and 2) general geographic information as anonymous sharing thereof for public awareness in the form of articles, info graphics or graphs. *

Yes

Required

If your choice was "No" (I don't consent), please provide a brief description.

By clicking "I accept", I understand that information contained on the miRic platform is to be used at my own discretion. *

I accept

Required

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms