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From the 10/8/2021 release of VAERS data:

This is VAERS ID 916074

Case Details

VAERS ID: 916074 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
Location: Illinois  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Public       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None
Preexisting Conditions: Unknown
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: MODERNA COVID-19 VACCINE EUA: Individual presented to COVID-19 vaccination clinic sponsored by Health Department being held for Healthcare Providers. Individual marked on Vaccination Consent form that she was a Medical Assistant at her father''s medical practice. After administration of vaccine it was discovered that she is 17 years old. This vaccine is not for individuals < 18 years old. Call made to CDC who advised us to call Moderna. Called Moderna and awaiting guidance/advice from Moderna Medical Information division.

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