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From the 5/14/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 919637

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Case Details

VAERS ID: 919637 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2020-01-04
Onset:2020-01-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025L20A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, No adverse event
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse reaction - vaccine was administered to a employee that was 17 years of age


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=919637


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