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This is VAERS ID 910883

History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 910883
VAERS Form:2
Age:15.0
Sex:Male
Location:Colorado
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025-J20-2A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: No adverse event, Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: No
Allergies: None
Diagnostic Lab Data: No adverse event this is an administration error
CDC 'Split Type':

Write-up: Individual was under 18 years of age


Changed on 5/7/2021

VAERS ID: 910883 Before After
VAERS Form:2
Age:15.0
Sex:Male
Location:Colorado
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025-J20-2A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: No adverse event, Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: No
Allergies: None None
Diagnostic Lab Data: No adverse event this is an administration error
CDC 'Split Type':

Write-up: Individual was under 18 years of age


Changed on 5/14/2021

VAERS ID: 910883 Before After
VAERS Form:2
Age:15.0
Sex:Male
Location:Colorado
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025-J20-2A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: No adverse event, Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: No
Allergies: None None
Diagnostic Lab Data: No adverse event this is an administration error
CDC 'Split Type':

Write-up: Individual was under 18 years of age

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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=910883&WAYBACKHISTORY=ON


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