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If you’d like to share an experience about pertussis, whether it’s about you or someone close to you, please fill in the information below.

Your comments will not be seen by anyone who can give you specific health-care advice. Do not use this form to report medical-related problems or to ask medical questions. Talk to your health-care provider if you have any medical questions, concerns, or problems.

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By completing this submission, I authorize Sanofi Pasteur Inc. ("sanofi pasteur") and its respective agents, licensees, successors and assignees (herein collectively called "Licensed Parties") to use the following information about myself: name, image, likeness, photo, and biographical information, and testimonial statements (collectively "Information"). I also understand that this Information will be used in conjunction with promotional materials regarding: Sounds of Pertussis. I understand that no compensation will be paid to me by the Licensed Parties or anyone for the use of the Information.

It is agreed that the Licensed Parties may copyright any materials developed by them that contain the Information, and such materials shall be owned by them. I hereby grant the Licensed Parties the right to use the Information and grant them the right to give, sell, transfer, exhibit, and use any and all such Information for all purposes, including advertising, promotion, and merchandising to any individual, business, firm, or publication or to any of their assignees, initiated, sponsored, or approved by the Licensed Parties. I agree not to authorize the use of the Information by any other person or entity without the prior written consent of Sanofi Pasteur Inc. or its designee. To the best of my knowledge this license does not in anyway conflict with any existing commitment on my part.

I agree that no material containing the information need be submitted to me for approval and the Licensed Parties shall be without liability to me for any distortion or illusionary effect resulting from the publication of my picture, portrait, or likeness. Further, I hereby give to the Licensed Parties all right, title and interest I may have in any Information that I have already, or may in the future, provide to the Licensed Parties, and I relinquish and give to the Licensed Parties all right, title, and interest I may have in the finished advertisements, reproductions, and copies thereof. Nothing herein will constitute any obligation on the Licensed Parties to make any use of the rights set forth herein.

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Thank you for sharing your story. Remember to help protect yourself and the infants close to you through adult pertussis immunization.