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, 1956 and December, 1967, please fill out the form below in its entirety. Also please upload a photo of yourself that shows your disability, and send to the USTS Communications Director at info@usthalidomide.org, with your name noted in the subject line.

A volunteer fellow thalidomide survivor will contact you within two weeks after your form has been submitted.

Please note that incomplete forms may not be processed. If you need assistance, please email survey.help@usthalidomide.org.

Can’t see the form below? Click here.