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From the 5/7/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 943674

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Case Details

VAERS ID: 943674 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-01-02
Onset:2021-01-02
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Product preparation issue
SMQs:, Medication errors (broad)

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: none known
Diagnostic Lab Data:
CDC Split Type:

Write-up: Error: Wrong Vaccine Formulation (ex. different manufact. initial and booster)


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Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=943674


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