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This is VAERS ID 953901

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 953901
VAERS Form:2
Age:17.0
Sex:Female
Location:Washington
Vaccinated:2021-01-15
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 AR / IM

Administered by: Private      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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Moderna COVID-19 Vaccine EUA Patient incorrectly indicated age on authorization form - indicated birthdate in 2002 and age not under 18. Shot given. Patient with no known adverse effects at this time.


Changed on 5/7/2021

VAERS ID: 953901 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:Washington
Vaccinated:2021-01-15
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 AR / IM

Administered by: Private      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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A N/A
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Moderna COVID-19 Vaccine EUA Patient incorrectly indicated age on authorization form - indicated birthdate in 2002 and age not under 18. Shot given. Patient with no known adverse effects at this time.


Changed on 5/21/2021

VAERS ID: 953901 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:Washington
Vaccinated:2021-01-15
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 AR / IM

Administered by: Private      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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A N/A
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Moderna COVID-19 Vaccine EUA Patient incorrectly indicated age on authorization form - indicated birthdate in 2002 and age not under 18. Shot given. Patient with no known adverse effects at this time.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=953901&WAYBACKHISTORY=ON


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