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

This is VAERS ID 919455



Case Details

VAERS ID: 919455 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Male  
Location: New York  
Vaccinated:2021-01-04
Onset:2021-01-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: No adverse event, Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Vaccine administered to 16 year old patient in error; FDA authorized emergency use of administered vaccine for patient''s 18 years and older. Patient was monitored for 15 minutes following vaccine administration; no adverse reaction noted.


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=919455

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