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 USATS Communications Director at cjean.oconnor@usathalidomide.org with your name noted in the subject line.

Please note that incomplete forms may not be processed. If you need assistance, please email coleen.callahan@usathalidomide.org.

Can’t see the form below? We can fill out the form for you; contact cjean.oconnor@usathalidomide.org.