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This is VAERS ID 951962

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/16/2021

VAERS ID: 951962
VAERS Form:2
Age:17.0
Sex:Unknown
Location:Illinois
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported Medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: 17 year old received the vaccine; A spontaneous report was received from a pharmacist concerning a 17-year-old patient who received Moderna''s COVID-19 vaccine (mRNA-1273) resulting in the event, 17 year old received the vaccine. The patient''s medical history was not provided. No concomitant medications were reported. On 04 Jan 2021, the patient received their first of two planned doses of mRNA-1273 intramuscularly in the deltoid for prophylaxis of COVID-19 infection. On 04 Jan 2021, the 17-year-old patient received the mRNA-1273 vaccine. The patient did not experience any symptoms and did not receive any treatments. Action taken with mRNA-1273 in response to the event was unknown. The event, 17 year old received the vaccine, was considered resolved on 04 Jan 2021.; Reporter''s Comments: This report refers to a case of 17- year-old female patient who received the mRNA-1273 vaccine (Inappropriate age at vaccine administration) Lot # was not provided. There were no reported AEs associated with this case of Incomplete dose administered


Changed on 5/7/2021

VAERS ID: 951962 Before After
VAERS Form:2
Age:17.0
Sex:Unknown
Location:Illinois
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported Medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: 17 year old received the vaccine; A spontaneous report was received from a pharmacist concerning a 17-year-old patient who received Moderna''s COVID-19 vaccine (mRNA-1273) resulting in the event, 17 year old received the vaccine. The patient''s medical history was not provided. No concomitant medications were reported. On 04 Jan 2021, the patient received their first of two planned doses of mRNA-1273 intramuscularly in the deltoid for prophylaxis of COVID-19 infection. On 04 Jan 2021, the 17-year-old patient received the mRNA-1273 vaccine. The patient did not experience any symptoms and did not receive any treatments. Action taken with mRNA-1273 in response to the event was unknown. The event, 17 year old received the vaccine, was considered resolved on 04 Jan 2021.; Reporter''s Comments: This report refers to a case of 17- year-old female patient who received the mRNA-1273 vaccine (Inappropriate age at vaccine administration) Lot # was not provided. There were no reported AEs associated with this case of Incomplete dose administered


Changed on 5/21/2021

VAERS ID: 951962 Before After
VAERS Form:2
Age:17.0
Sex:Unknown
Location:Illinois
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported Medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: 17 year old received the vaccine; A spontaneous report was received from a pharmacist concerning a 17-year-old patient who received Moderna''s COVID-19 vaccine (mRNA-1273) resulting in the event, 17 year old received the vaccine. The patient''s medical history was not provided. No concomitant medications were reported. On 04 Jan 2021, the patient received their first of two planned doses of mRNA-1273 intramuscularly in the deltoid for prophylaxis of COVID-19 infection. On 04 Jan 2021, the 17-year-old patient received the mRNA-1273 vaccine. The patient did not experience any symptoms and did not receive any treatments. Action taken with mRNA-1273 in response to the event was unknown. The event, 17 year old received the vaccine, was considered resolved on 04 Jan 2021.; Reporter''s Comments: This report refers to a case of 17- year-old female patient who received the mRNA-1273 vaccine (Inappropriate age at vaccine administration) Lot # was not provided. There were no reported AEs associated with this case of Incomplete dose administered

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