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.

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.