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This is VAERS ID 916074

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 916074
VAERS Form:2
Age:17.0
Sex:Female
Location:Illinois
Vaccinated:2020-12-30
Onset:2020-12-30
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: 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: 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.


Changed on 5/7/2021

VAERS ID: 916074 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:Illinois
Vaccinated:2020-12-30
Onset:2020-12-30
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: 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: Unknown
Current Illness: None
Preexisting Conditions: Unknown
Allergies: None 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.


Changed on 5/14/2021

VAERS ID: 916074 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:Illinois
Vaccinated:2020-12-30
Onset:2020-12-30
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: 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: Unknown
Current Illness: None
Preexisting Conditions: Unknown
Allergies: None 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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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=916074&WAYBACKHISTORY=ON

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