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This is VAERS ID 955921

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 955921
VAERS Form:2
Age:17.0
Sex:Female
Location:New York
Vaccinated:2021-01-15
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was 17 when vaccine was administered (authorized for 18 and older). No known adverse events.


Changed on 5/7/2021

VAERS ID: 955921 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:New York
Vaccinated:2021-01-15
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was 17 when vaccine was administered (authorized for 18 and older). No known adverse events.


Changed on 5/21/2021

VAERS ID: 955921 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:New York
Vaccinated:2021-01-15
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was 17 when vaccine was administered (authorized for 18 and older). No known adverse events.

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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=955921&WAYBACKHISTORY=ON


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