Be counted!

We want to find all U.S. survivors of the drug thalidomide for our future advocacy efforts.

If you believe you are a survivor of thalidomide, and were born in the United States between December 1, 1957 and December 31, 1967, please fill out the form below in its entirety. Also please email a photo of yourself that shows your disability to the USTS Communications Director at, with your name noted in the subject line.

Please note that incomplete forms may not be processed. If you need assistance, please email

Can’t see the form below? Click here.