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Keep Antibiotics Working (KAW) is a coalition of health, consumer, environmental, humane, and other advocacy groups working to curtail the inappropriate use of medically important antibiotics in animal agriculture. If you or a family member has been ill with an antibiotic-resistant bacterial infection, please fill out the form below. The information will be kept totally confidential. We may contact you for additional information or to ask if you are willing to speak with someone about your experiences. Thank you!

* denotes required fields

*Brief description of illness:

*When did the illness occur? 

*How did the doctor determine the illness was resistant to antibiotics?

*Any diagnosis given?  Yes   No

*If yes, what?

*Which antibiotics were taken?

Any additional details you would like us to know? (optional)

* City:    * State:    * Zip: 

* Phone:    Ext. 

Name and age of person who was ill:

* Name:    * Age: