The New York Times would like to hear what doctors and nurses across the country are experiencing when it comes to patients’ concerns or misgivings about longstanding vaccines, especially for polio.

You can submit your name, contact information and a summary of what is happening in your practice in the form below. The reporters, Sheera Frenkel and Ellen Gabler, will reach out to you directly and will not publish your name or any of the information you submit without your permission and without speaking with you first.