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From the 1/14/2022 release of VAERS data:

Found 1,031,637 cases where Vaccine is COVID19 and Patient Did Not Die

Government Disclaimer on use of this data



Case Details (Reverse Sorted by Onset Date)

This is page 587 out of 10,317

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VAERS ID: 1869618 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 069F21A / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Extra dose administered, Interchange of vaccine products
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: Unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient came to clinic for Moderna booster. Presented card that indicated he recieved J&J in March. This was confirmed with the patient. When recording the vaccine in database, the system showed he had also had a Pfizer vaccine in July that he failed to report.


VAERS ID: 1869625 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 RA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UT7336NA / N/A LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Rash, Rash macular, Somnolence
SMQs:, Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Vitals taken by clinic staff.
CDC Split Type:

Write-up: About 10 minutes after both vaccines were administered, patient developed rash on both arms in elbow area, a small rash on chest, and several small blotches on neck. A single dose of oral diphenhydramine 25mg was administered. After 45 minutes of observation, the patient was released from care. Rashes were almost completely resolved, and patient said she was only experiencing mild dizziness/drowsiness.


VAERS ID: 1869639 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 2 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UJ705AA / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, Incorrect dose administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
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: Pt was in office for a visit, was given a flu vaccine and a Covid vaccine, but received the pediatric dose of the covid instead of the 12 yr and up


VAERS ID: 1869656 (history)  
Form: Version 2.0  
Age: 8.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

Administered by: School       Purchased by: ?
Symptoms: Condition aggravated, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (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: Flu Vaccination - Flulaval- Nov 2019
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: Child became syncopal after shot. Mom at child?s side. Child stated,? I?m going to faint,?. Child curled up into mom?s lap; airway patent, skim warm and dry. Episode lasted three minutes. Child up and walking, smiling, choosing stickers. Mom remained at child?s side. Mom stated, ?She always does this,?.


VAERS ID: 1869661 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-11-08
Onset:2021-11-15
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Palpitations, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (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: advil
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: ongoing fever and heart palpitations


VAERS ID: 1869668 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039F21A / 2 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Hypoaesthesia, Pain in extremity
SMQs:, Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Tendinopathies and ligament disorders (broad), Sexual dysfunction (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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pain and numbness in hand


VAERS ID: 1869701 (history)  
Form: Version 2.0  
Age: 10.0  
Sex: Male  
Location: Kansas  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH BNT162B2 / 1 - / IM

Administered by: Work       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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: At the end of the COVID vaccine clinic on 11/11/2021 at approximately 1715 I, RN Nurse Manager of the clinic realized that additional doses of the COVID clinic would need to be mixed and drawn up for the remaining patients on the schedule. I went into the medication room to mix a vial of the COVID vaccine with normal saline as I had been taught to do earlier in the day with Pharmacist. I opened the red bag of supplies to mix up the vaccine and only found one vial in the bag with a salmon colored top. Remembering that that the vaccine came in a vial with an orange top I believed this to be the vaccine and was looking for the diluent. Unable to locate some I called pharmacist and she informed me that I was fine to use normal saline from another source to mix the vaccine. I located another source of normal saline within the clinic and used it to mix 1.3ml of normal saline into the vial. After following the mixing instructions of inverting the initial vial 10x, added the diluent, removed 1.3ml of air, and then inverted the vial 10x to mix, I then drew up multiple syringes of 0.2ml RN and MA each took two syringes to vaccinators who were waiting to administer the vaccine to patients. approximately 10-15 minutes later another HCP and I called pharmacist to ensure I knew how to properly dispose of the unused vaccine. It was during this conversation that I realized I had not used the COVID vaccine vial but had used the diluent vial and had mixed additional NACL into the diluent vial. I immediately asked who had received the last 4 doses, 3 of those patients were still in the building and 1 patient had left. I notified the parents of the 3 patients who were still on the premises of the error that was made and apologized. I then asked if they would still like the patient to receive the COVID vaccine tonight and the parents agreed. Those 3 patients each received a dose after I went back into the med room and correctly mixed the vaccine. The patients remained under observation for 15 minutes and were then discharged. None of these patients experienced any negative effects while under observation. A phone call and message was left/sent to the parent of the 4th patient that night and the following morning another phone call was placed to the patient''s father and the situation explained. Father agreed to bring the patient in on the following Monday in order to receive the COVID vaccine.


VAERS ID: 1869725 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33026BD / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered, Product preparation issue
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
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: patient was given the incorrect dose. the 12+ formulation was used and mixed using 1.3ml diluent and 0.2ml dose was given to the patient. Patient received a higher dose than she should have.


VAERS ID: 1869728 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-05
Onset:2021-11-15
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 051F21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Injection site pain, Mobility decreased
SMQs:, Parkinson-like events (broad), Extravasation events (injections, infusions and implants) (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No
Current Illness: No
Preexisting Conditions: Not available
Allergies: No
Diagnostic Lab Data: Patient is advised to seek doctor for check up or treatment.
CDC Split Type:

Write-up: Pt received Moderna booster on 11/5/21 on her left shoulder & came and reported 11/15/21 her left shoulder still very painful and her arm movement is still limited due to the vaccination


VAERS ID: 1869729 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 301558A / 2 AR / IM

Administered by: Military       Purchased by: ?
Symptoms: Condition aggravated, Paraesthesia, Pharyngeal swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Peripheral neuropathy (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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: PATIENT HAD THROAT SWELLING AND PARETHESIA. PFIZER-BIONTECH FIRST DOSE
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT SELF-MEDICATED WITH TYLENOL(1000MG) AND BENADRYL(50MG) AT 0906 PRIOR TO RECEIVING COVID-19 VACCINE. PATIENTED PRESENTED WITH SYMPTOMS OF MILD THROAT SWELLING AND PINS AND NEEDLES SENSATION(PARESTHESIA) IN EXTREMITIES BILATERALLY. VITAL SIGNS WERE TAKEN AT 0944, 0947 AND 1014 AM. DOCTOR CALLED AT 1020 AM; DOCTOR SAW PATIENT AT 1028 AM. PATIENT DISCHARGED FROM COVID-19 VACCINE SITE AT 1048 AM. VITAL SIGNS; @0944 B/P: 154/103 HR: 68 R/R: 20 SPO2: 100% TEMP. 98.4 F ORALLY @0947 B/P: 142/93 @1014 AM B/P: 125/84 HR: 66 R/R: 16 SPO2: 100% TEMP.: 97.8 F ORALLY


VAERS ID: 1869730 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0191 / 3 LA / IM

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

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: Patient was given a dose of Pfizer that was double diluted.


VAERS ID: 1869737 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ1611 / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

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: PASSED OUT, PATIENT RESPONDED SHORTLY AFTER, PATIENT WAS ABLE TO LEAVE UNDER HIS OWN POWER


VAERS ID: 1869739 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0191 / 3 LA / IM

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

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: Patient was given a Pfizer Covid vaccine that had been double diluted.


VAERS ID: 1869741 (history)  
Form: Version 2.0  
Age: 8.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33020BD / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad), 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: child received incorrect dose of vaccine - patient is 8yo and should have received the pediatric formulation. The pharmacist mistakenly used the 12+ yo formulation and mixed and administered according to the pediatric specifications (1.3ml diluent and 0.2ml dose). Mom reports the child is feeling ok- has a sore arm, reports no other side-effects at this time.


VAERS ID: 1869748 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 211D21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anxiety, Dizziness, Hypotension, Immediate post-injection reaction, Nausea
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypersensitivity (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (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: na
Current Illness: na
Preexisting Conditions: na
Allergies: na
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient received Janssen booster vaccine and immediately felt lightheaded, feeling of wanting to throw up, dizzy. pharmacist measured blood pressure reading and it was low, paramedics evaluated patient told us it was most likely due to anxiety


VAERS ID: 1869779 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: California  
Vaccinated:2009-12-22
Onset:2021-11-15
   Days after vaccination:4346
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / 1 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLULAVAL QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS 49LC5 / 1 RA / IM

Administered by: Work       Purchased by: ?
Symptoms: Seizure like phenomena
SMQs:, Convulsions (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions: unknown
Allergies: egg whites
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received covid vaccine then flu vaccine (lot 49LC5) right after. Started having seizure like episode. MD stat and EMTs called. Pt went to local ED via ambulance.


VAERS ID: 1869782 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 0.5 mL was administered -should have been 0.25 mL for booster dose.


VAERS ID: 1869789 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Extra dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: 0.5 mL was administered, should have been 0.25 mL for booster dose


VAERS ID: 1869796 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Extra dose administered, Incorrect dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: was administered 0.5 mL, should have been 0.25 mL for booster dose


VAERS ID: 1869800 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: was administered 0.5 mL, should have been 0.25 mL for booster dose


VAERS ID: 1869803 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-03-05
Onset:2021-11-15
   Days after vaccination:255
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6206 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
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: COVID +


VAERS ID: 1869805 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ8757 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Dizziness, Throat tightness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Vestibular disorders (broad), Hypersensitivity (broad)

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: anaphylaxis
Other Medications: no
Current Illness: no
Preexisting Conditions: no
Allergies: miralax, polyethelyne glycol, procaine, ibuprofen, acetaminophen
Diagnostic Lab Data: vitals; O2 100%; BP 176/82
CDC Split Type:

Write-up: Patient complaining of throat tightening and light headedness


VAERS ID: 1869813 (history)  
Form: Version 2.0  
Age: 22.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8030 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Back pain, Pain, Pain in extremity
SMQs:, Retroperitoneal fibrosis (broad), Tendinopathies and ligament disorders (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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient having arm pain along with back pain on the same side as the vaccine site. She also reports shooting pains in her fingers on her left hand as well.


VAERS ID: 1869815 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: administered 0.5 mL, should have been 0.25 mL for booster dose


VAERS ID: 1869818 (history)  
Form: Version 2.0  
Age: 5.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33026BD / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arthralgia, Pain in extremity, Product administered to patient of inappropriate age
SMQs:, Arthritis (broad), Tendinopathies and ligament disorders (broad), 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: child should have gotten the pediatric dose, but the 12+ formulation was used but diluted and administered with the pediatric guidelines (1.3ml diluent and 0.2ml dose). mom reports child complaining of sore arm and achy joints.


VAERS ID: 1869822 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: administered 0.5 mL- should have been 0.25 mL for booster dose


VAERS ID: 1869839 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: administered 0.5 mL, should have been 0.25 mL for booster dose


VAERS ID: 1869851 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-11-03
Onset:2021-11-15
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939904 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Laboratory test, Platelet count, Postmenopausal haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

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: Omepersole Atorvastatin Glucosamine
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Seeing doctor for tests and platelet count
CDC Split Type:

Write-up: Post menopausal bleeding


VAERS ID: 1869852 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: administered 0.5 mL, should have been 0.25 mL for booster dose


VAERS ID: 1869855 (history)  
Form: Version 2.0  
Age: 34.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Facial paralysis, Hypoaesthesia
SMQs:, Peripheral neuropathy (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Hearing impairment (broad), Sexual dysfunction (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluoxetine
Current Illness:
Preexisting Conditions:
Allergies: Dairy allergy, Bactrim
Diagnostic Lab Data:
CDC Split Type:

Write-up: Numbness in right side of face, neck and down the length of right arm. Also seeing drooping of cheek on right side of face.


VAERS ID: 1869868 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Female  
Location: North Dakota  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FC3181 / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Body temperature increased, Chest discomfort, Diarrhoea, Energy increased, Fatigue, Immediate post-injection reaction, Impaired work ability, Insomnia, Loss of consciousness, Seizure like phenomena, Throat tightness, Urticaria, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Pseudomembranous colitis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (narrow), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram and Sprintec.
Current Illness: None.
Preexisting Conditions: None.
Allergies: None.
Diagnostic Lab Data: As of now, none.
CDC Split Type:

Write-up: I passed out immediately after the shot and had seizure like activities, then proceeded to vomit for 2 hours. The night of incident I was not able to sleep because I felt very energetic. I was off of work a day due to feeling very tired, running a temp of 100.4, and having diarrhea. For two days after the event I was really tired. A week after the event my throat and chest started to tighten. On November 1st hives started forming on my arms. On November 13th hives spread all over body.


VAERS ID: 1869877 (history)  
Form: Version 2.0  
Age: 10.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330268D / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad), 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: patient received incorrect dose of vaccine- patient should have received the different formulation, but the adult (12+) vial was used and diluted/administered according to the specifications (1.3ml diluent and 0.2ml dose). Mom reports sore arm, but no other side effects at this time.


VAERS ID: 1869914 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-11-13
Onset:2021-11-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30155BA / UNK RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Axillary mass, Headache, Hypersomnia
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Depression (excl suicide and self injury) (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: Not Applicable
Current Illness: Not Applicable
Preexisting Conditions: Not Applicable
Allergies: NKA
Diagnostic Lab Data: Not Applicable
CDC Split Type:

Write-up: Lump under right armpit. No pain. I had headache the following day but is resolved now. I was sleeping the whole day Sunday. I did not take any medication but kept myself hydrated. I noticed a swelling in my armpit Monday morning.


VAERS ID: 1869935 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: California  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011F21A / 1 UN / IM

Administered by: Private       Purchased by: ?
Symptoms: Extra dose administered, Incorrect dose administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received JJ and requested to get moderna as supplemental. Provider okayed this and the staff member gave patient the supplemental full dose. Per the guidelines patients that received their first dose and are supplemental patients should get the same vaccines as boosters and supplemental. Patient should have received JJ or if they had received booster they should have gotten half dose. Patient was made aware by provider.


VAERS ID: 1869964 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Incorrect dose administered, Needle issue, Syringe issue
SMQs:, Medication errors (narrow)

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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: At 11:30am Patient received a Pfizer booster in his left deltoid. After shot was administered, the needle hub fell off when the nurse attempted to put the safety cap on. There were a few drops of fluid next to the needle after it was disengaged. The patient stated he knew he got about 95% or more of the vaccine. However, he was worried about the 2 or 3% he didn''t get. Patient said he wanted to request an antibody test. Site leaders were informed.


VAERS ID: 1869976 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1869979 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-11-04
Onset:2021-11-15
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041C21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: No symptoms; vaccine given unintentionally after the expiration date.


VAERS ID: 1869982 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1869987 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1869988 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-11-01
Onset:2021-11-15
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 067F21A / 1 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS ZG474 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Feeling hot, Flushing, Hyperhidrosis, Inappropriate schedule of product administration
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Vestibular disorders (broad), Hypersensitivity (broad), Medication errors (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE Known
Current Illness: None Reported
Preexisting Conditions: None reported
Allergies: None KNown
Diagnostic Lab Data: None KNown
CDC Split Type:

Write-up: Moderna Booster and Fluarix administerd. opposite arms. after second shot adm. pt fell faint, but remained conscious. Pt was hot, sweating and flushed. Paramedics called and pt cared for. Offered Ice pack, water and Glucose tablet . pt was seated.


VAERS ID: 1869990 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-11-04
Onset:2021-11-15
   Days after vaccination:11
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041C21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: No symptoms to vaccine, Vaccine was given i=unintentionally to patient after the expiration date on bottle.


VAERS ID: 1869993 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1869998 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Product storage error
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870000 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 213D21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood glucose decreased, Hyperhidrosis, Nausea, Syncope, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (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: none that I am aware of
Current Illness: none that I am aware of
Preexisting Conditions: none that I am aware of
Allergies: codiene
Diagnostic Lab Data: none
CDC Split Type:

Write-up: we gave a Janssen Covid imz (1st dose) to the pt. Pharmacy Immunizing tech gave the IMZ. After receiving the IMZ, the pt was seated in the pharmacy area waiting the 15 minutes as instructed. Tech noticed the pt was on the floor and he went out to assist the pt. As tech was helping the pt I went to assist and asked the pt if he needed us to call an ambulance and he said no. We gave him some water and he said he felt like he had low blood sugar so we gave him some candy to eat. After eating the candy and drinking a couple glasses of water he said he felt like nauseated. I brought out a trash can to give to the pt and he threw up a little. I did notice he had some sweat on his forehead and the pt was wearing a winter hat and a jacket so the fainting could have been because he was overheated or a combination of low blood sugar and being over heated. Store management did come around and asked if teh pt needed an ambulance. The pt stayed in the pharmacy area for about 15 minutes and he regained composure. He had called someone to ask for a ride. I went out again to make sure he was allright and he said his ride was here to pick him up and he left.


VAERS ID: 1870003 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870005 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-07-14
Onset:2021-11-15
   Days after vaccination:124
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870009 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-14
Onset:2021-11-15
   Days after vaccination:124
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870017 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870020 (history)  
Form: Version 2.0  
Age: 64.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870024 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-13
Onset:2021-11-15
   Days after vaccination:125
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870031 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-07-14
Onset:2021-11-15
   Days after vaccination:124
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Product storage error
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870033 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Dyspnoea, Flushing
SMQs:, Anaphylactic reaction (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (broad)

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: Pt received Moderna covid-19 vaccine Booster at 11:11, c/o flushing and mild sob 14mins after vaccine administration. Pt was asssisted to gurney and was placed on his back with hob raised to 30 degrees. V/s taken per protocol. Benadryl 50mg tabs were administered. Allergist Dr. was notified, instructed to keep for an additional 30min. Pt left facility at 11:58am, denies any allergies symptoms. Instructed patient to call 9-11 or go to ER if symptoms worsen later during the day.


VAERS ID: 1870035 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-14
Onset:2021-11-15
   Days after vaccination:124
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 1 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870036 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-07-14
Onset:2021-11-15
   Days after vaccination:124
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870038 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 069F21A / 3 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Injection site pruritus, Injection site reaction, Rash erythematous
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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: both her previous Moderna vaccines
Other Medications: Fluticasone Meloxicam Omeprazole
Current Illness: none per pt
Preexisting Conditions: Seasonal Allergies Asthma Chronic Low Back Pain GERD Hyperlipidemia
Allergies: No Known Drug Allergies
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Approximately 30 minutes post pt''s 3rd Moderna vaccine pt developed "itching" to L upper arm with random, flat, red rash to L upper arm only. Pt denied any other symptoms but indicated that with her previous 2 Moderna vaccines, she developed itching and red rash within 24-48 hours of her vaccine to her generalized body in which she took otc Benadryl for and obtained relief. Pt was evaluated by PA-C and verbal order for Ceterizine 10mg po given. Pt tolerated very well and after monitoring, pt stated that her "itching" was "getting better". She did not develop any other symptoms and denied any acute respiratory distress. After re-evaluation, pt did not have any worsening of her symptoms and stated she was "feeling better" in which she was discharged home to follow up with PCP or seek medical care in the ED should her symptoms not improve, changes, worsens or becomes life threatening.


VAERS ID: 1870042 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-14
Onset:2021-11-15
   Days after vaccination:124
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Product storage error
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870044 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FG3527 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anxiety, Dry throat, Paraesthesia oral, Throat tightness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Hypersensitivity (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown by writer
Current Illness: none reported to writer
Preexisting Conditions: unknown by writer
Allergies: Anaphylactic reaction to Augmentin in the past.
Diagnostic Lab Data: none I am aware of
CDC Split Type:

Write-up: Vaccine administered 0853. With history of anaphylaxis was required to stay for 30 minutes for observation. began to experience tingling lips, "tight" throat, and anxiety at approximately 0908. Writer gave her water and 2 oral 25 mg Benadryl at 0910. BP 142/82, HR 90, RR 22. 7 minutes later BP 135/78, HR 88, RR 22. Employee slightly less anxious. Throat feeling less "tight" and more dry. Lips slightly less tingly. Kept for observation until symptoms continued to decrease. Was escorted to her clinical work area by co-worker at 0933. She returned to the vaccination area around 1030 because her throat continued to feel "kind of tight". Writer explained at this point in time post vaccination, and care for her symptoms would need to be addressed through a medical provider such as a clinic or emergency department and not through the vaccination clinic. She then went back to her clinical work area. Writer received a phone call later in the day from her stating she sought care at the Hospital Emergency Department around 11:20a.m. after she went home for the day as her throat was continuing to feel tight. She received an exam from the provider, but no medications.


VAERS ID: 1870045 (history)  
Form: Version 2.0  
Age: 10.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330268D / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect product formulation administered, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad), 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: patient was to receive the pediatric covid vaccine, but the adult dose vial was selected and mixed/administered according to the pediatric directions (1.3ml diluent and 0.2ml dose). mom reports soreness in the arm, but no other side-effects at this time.


VAERS ID: 1870046 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-14
Onset:2021-11-15
   Days after vaccination:124
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 2 - / -

Administered by: Public       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Stored beyond use date. Moderna analysis revealed full strength persisted.


VAERS ID: 1870048 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-11-13
Onset:2021-11-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013F21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Injection site pain, Neck pain
SMQs:, Extravasation events (injections, infusions and implants) (broad), Arthritis (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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: fish, macadamia nuts
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient is experiencing muscle soreness at injection site and neck pain (entire neck)


VAERS ID: 1870052 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Malaise
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

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: no allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient stated that he felt dizzy after he left pharmacy area and went shopping. It was almost an hour after the vaccination that he stated he was not feeling well. He called his daughter and she came and picked him up. He walked out of the store and seemed to be fine.


VAERS ID: 1870054 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: Maine  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Inappropriate schedule of product administration
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: None Known
Current Illness: None Known
Preexisting Conditions: None Known
Allergies: None Known
Diagnostic Lab Data: None
CDC Split Type:

Write-up: The client came into the clinic with her parental consent to get the Pfizer vaccine. She recieved the vaccine. When staff was entering it into database, they noticed that the client had already recieved the COVID-19 vaccine 3 days prior (11/12/2021). The consent had the parent''s signature and the question of whether or not the child had the vaccine before was answered "no". The supervisor called the parent to notify him that the patient recieved the dose of Pfizer 3 days after the initial dose. No adverse effects have been noted thus far. The patient weighs 130 lbs.


VAERS ID: 1870056 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 09D21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Anxiety, Chest pain, Flushing, Hyperventilation, Nausea, Rash, Vomiting
SMQs:, Anaphylactic reaction (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (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: Unknown
Current Illness: None day of.
Preexisting Conditions: Unknown
Allergies: NKDA
Diagnostic Lab Data: Taken to ED
CDC Split Type:

Write-up: Anxiety, flushed, hyperventilation, Nausea, Vomiting, and Chest Pain, stated bumps


VAERS ID: 1870067 (history)  
Form: Version 2.0  
Age: 5.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330268D / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad), 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: patient should have gotten the pediatric pfizer covid-19 vaccine, but the incorrect vial was selected so patient received a higher dose than he should have. the adult vial was used, but mixed according to the pediatric vial instructions (1.3ml diluent) and 0.2ml vaccine was given. mom reports sore arm at this time, but patient does have a history of cardiac illness, so they will follow up with pediatrician and cardiologist.


VAERS ID: 1870069 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-11
Onset:2021-11-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Injection site erythema, Injection site pain, Injection site warmth
SMQs:, Extravasation events (injections, infusions and implants) (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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Redness, heat, tenderness at the injection site starting ~6 days following injection.


VAERS ID: 1870076 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-13
Onset:2021-11-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30155BA / 3 - / -

Administered by: School       Purchased by: ?
Symptoms: Lymphadenopathy
SMQs:, Drug reaction with eosinophilia and systemic symptoms syndrome (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: None.
Current Illness: None.
Preexisting Conditions: None.
Allergies: None.
Diagnostic Lab Data:
CDC Split Type:

Write-up: knot under armpit on the side of injection site.


VAERS ID: 1870079 (history)  
Form: Version 2.0  
Age: 8.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330268D / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad), 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: patient should have received the pediatric covid-19 vaccine, but the dose was administered incorrectly. The adult vial was used, but then mixed and administered with 1.3ml diluent and 0.2ml dose. mom reports no additional side-effects other than a sore arm at this time.


VAERS ID: 1870082 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037C21A / 3 RA / IM

Administered by: Work       Purchased by: ?
Symptoms: Arthralgia, Discomfort, Dizziness, Hypotension
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Vestibular disorders (broad), Arthritis (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Synthroid, NPH Insulin, Lipitor, Cymbalta
Current Illness:
Preexisting Conditions: Diabetes, Hypertension, Peripheral neuropathy, High cholesterol
Allergies: Iodine, IVP dye, Lopid, Codeine, Statins, Trazodone
Diagnostic Lab Data:
CDC Split Type:

Write-up: lighthead, hypotensive, heaviness feeling over body, joint pain


VAERS ID: 1870088 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-11-11
Onset:2021-11-15
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 051F21A / 3 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cellulitis
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
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: Patient was diagnosed with cellulitis by PCP 4 days after receiving Moderna COVID Vaccine


VAERS ID: 1870096 (history)  
Form: Version 2.0  
Age: 5.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330268D / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered, Product preparation issue
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: patient received the incorrect dose of covid-19 vaccine. patient should have received the pediatric dose, but the adult vial was used and diluted with 1.3ml diluent and dose given at 0.2ml. mom reports no additional unexpected side-effects at this time.


VAERS ID: 1870105 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-11-13
Onset:2021-11-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 320308D / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Swelling of eyelid
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Periorbital and eyelid disorders (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: Eye swollen shut. Mom called asking if possible from vaccine, same side as where received vaccine. I told mom she should bring her in to walk in.


VAERS ID: 1870106 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8028 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient was given the adult dose of Covid19 instead of the pediatric dose. We spoke with the patients mom and she said she would monitor the patient and get in touch with her doctor if anything arises.


VAERS ID: 1870107 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8030 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Malaise, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: no
Allergies: none
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient received first Pfizer vaccine and was sitting down for observation for about 3-5 mins before she reported not feeling well and very dizzy. She said she feels like fainting so I support her arm and upper shoulder and she fainted in her chair for about 30-40 seconds. We called emergency number to report the incident. She came back on her own and was conscious when the ambulance came. They came and gave her IV and transported her to hospital.


VAERS ID: 1870112 (history)  
Form: Version 2.0  
Age: 7.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330268D / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Extra dose administered, Pain in extremity
SMQs:, Tendinopathies and ligament disorders (broad), 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: patient should have received a pediatric dose of the covid-19 vaccine. a vial of the adult vaccine was used by mistake, mixed and administered using the instructions for the pediatric dose. (1.3ml diluent and 0.2ml dose administered). mom reports no unexpected side-effects at this time- just a sore arm right now.


VAERS ID: 1870113 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / 1 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UT7347MA / N/A RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Dizziness, Fall, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Adderall CR Melatonin Diphenhydramine
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: NKA
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient presented to clinic as walk in for a COVID-19 vaccine and flu vaccine. Patient received both vaccines as indicated above. Patient stood up and proceeded to the door in which she became faint with syncope response. Evaluated by Dr. with monitoring 30+ minutes following episode. Patient left with family to home. Patient did later present to hometown ED for evaluation due to concern of concussion from fall.


VAERS ID: 1870129 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: Rhode Island  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0191 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Chest discomfort, Dizziness, Hypoaesthesia, Paraesthesia, Sensory disturbance
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (narrow), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Vestibular disorders (broad), Sexual dysfunction (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations: J&J in April, Dr recommended getting Booster with Pfizer
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: numbness on the left side of her face and left side of her nose as well as tingling in her nose, after a few minutes, she then developed numbness on the right side of her face which progressed down the left side of her neck, pt reported a "weird" sensation in her chest and abdomen as well as feeling dizzy, some chest tightness.


VAERS ID: 1870131 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Male  
Location: New York  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1855194 / 1 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Headache, Hot flush
SMQs:

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: No
Current Illness: No
Preexisting Conditions: No
Allergies: No
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hot flash , headache


VAERS ID: 1870139 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 051F21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: No adverse event, Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Spoke with patient a few hours after finding out I gave her moderna vaccine when she was under 18 years old. She so far has no side effect from the vaccine. I told her to call me if she experiences any side effects.


VAERS ID: 1870153 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027C21A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Hypertension, Palpitations, Pharyngeal swelling, Tachycardia, Throat tightness
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypertension (narrow), Cardiomyopathy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: 38 year old female who has completed a 60-minute observation period with the following signs and symptoms of an adverse reaction: sensation of throat swelling or throat closure and other - Hypertension, Tachycardia, Palpitations. Moderna COVID-19 vaccine#2 in series administered. o Action(s) taken: Epinephrine administered and Another drug administered - Benadryl o Allergy to COVID-19 vaccine documented in Allergies activity: Yes o Patient advised to discuss second dose considerations with a clinician 1357- BP 169/92, HR 104, SpO2 97% 1358- Epi Administered 1400- MD in room evaluating patient. 1406- 50mg Benadryl PO given. BP 154/85, HR 103, SpO2 98%. 1420- 141/77, HR 88, SpO2 98% 1430- Per MD, Pt is safe for discharge. Strict ED instructions given to patient. 1406- Verbal order of Benadryl of 5o mg PO given by MD, 5 right of administration were checked. Medication read back to MD for verification.


VAERS ID: 1870157 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Unknown  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Feeling hot, Loss of consciousness, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PAtient received 1st Pfizer BioNTech 0.2mL immunization. During 15 minute post vaccination waiting epriod. Patietn father called for help, states "i asked him a question, he answered, i looked away for a second and when i looked back he was passed out and not responding". This RN arrived to patient prior to regain of conciousness. patient unocnsious for approximately 30-45 seconds. when he woke up he states "i feel fine, i jsut feel like i went to sleep, but i feel hot." Patient given water, Ice pack, and a snack. Patient monitored for an additional 15 minutes after event occured. Patient left feeling normal. Father advised to seek medical attention for any further issues or cocnerns.


VAERS ID: 1870161 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-03
Onset:2021-11-15
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017F21A / 3 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Injection site rash, Rash
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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: Prescription: Adderall XR, 15 mg (daily); Adderall IR, 5 mg (as needed)
Current Illness: N/A
Preexisting Conditions: HBP, ADHD
Allergies: penicillin (rash)
Diagnostic Lab Data: None
CDC Split Type:

Write-up: rash not at injection site; on trunk (stomach, back) and hands


VAERS ID: 1870177 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 091D21A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Underdose
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol inhaler, multivitamin, Advair, Xopenex
Current Illness: Unknown
Preexisting Conditions: Asthma
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna Booster Dose (0.25ML) inadvertently given to 11 year old.


VAERS ID: 1870189 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 091D21A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
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: No medications
Current Illness: Unknown
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Moderna Booster Dose (0.25ml) inadvertently given to 9 year old.


VAERS ID: 1870197 (history)  
Form: Version 2.0  
Age: 7.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 091D21A / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
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: No medications
Current Illness: unknown
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Moderna Booster dose (0.25ml) inadvertently given to 7 year old


VAERS ID: 1870202 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939909 / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Immunisation, Incorrect product formulation administered
SMQs:, Medication errors (narrow)

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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient was mistakenly administered 0.25ml of air initially before actually getting 0.25ml of moderna vaccine in different site but in same right arm. Patient''s doctor was informed about the incident. Patient left pharmacy after about 15 minutes of administration without signs of reaction.


VAERS ID: 1870206 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FF2593 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Fall, Malaise, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: NO KNOW ALLERGIES
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received their first dose of Pfizer COVID-19 vaccine. Patient was instructed to wait in the waiting area. Patient was sitting on the floor at the time. He was conversing with his brother (whom also received a Pfizer covid vaccine). He began to say that he wasn''t feeling well, then the patient collapsed. The patient came to in about 15 seconds. He reported that he began feeling really dizzy and next he knew he was on the floor.


VAERS ID: 1870224 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 213D21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Hypotonia, Paraesthesia, Paraesthesia oral, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Peripheral neuropathy (broad), Arrhythmia related investigations, signs and symptoms (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: ESCITALOPRAM 10MG TAB, BUPROPION XL 150MG TAB
Current Illness: Unknown
Preexisting Conditions: Unknown medical history
Allergies: None
Diagnostic Lab Data: Unknown
CDC Split Type: N/A

Write-up: Post-vaccination, patient was waiting in pharmacy. Husband was standing, and she was sitting. Husband reported that patient slumped head to the side and was demonstrating syncope. Immunizing pharmacist stabilized patient on floor pad, and she took vitals. Patient''s blood pressure and temperature were normal, and patient was alert and answering questions. She reported that she had "tingling" in her lips and arms. Local EMS responders arrived and transported patient for medical evaluation at local hospital.


VAERS ID: 1870225 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: No adverse event, Product preparation issue, Underdose
SMQs:, Medication errors (broad)

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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE KNOWN
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: THIS REPORT IS FOR AN ADMINISTRATION ERROR.. PT RECEIVED A LOWER DOSEAGE OF VACCINE DUE TO ERROR IN DILUENT ADDITION.. NO ADVERSE EFFECTES NOTES DURING OBSERVATION PERIOD.. FOLLOW UP TODAY SHOWS NO ADVERSE EFFECTS PER MOTHER


VAERS ID: 1870230 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Headache, Heart rate increased, Hypertension, Malaise, Nausea
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Vestibular disorders (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations: Same reaction after first dose of Moderna COVID-19. Date unknown to us.
Other Medications: Unknown. Patient has not filled here since June of 2021.
Current Illness: She had a similar reaction after first Moderna dose. No support was provided at that time.
Preexisting Conditions: Hyperlipidemia, rhinitis, hormone deficiency, osteoarthritis, dermatitis, GERD, Parkinson''s
Allergies: Diphenhydramine, tramadol, rauwolfia derivatives, penicillins, codeine, aspirin
Diagnostic Lab Data: Unknown
CDC Split Type:

Write-up: After waiting 15 minutes, patient got up and started shopping. She came back to pharmacy and reported feeling ill: dizzy, headache, nauseated. Rx Tech checked blood pressure which was very high and heart rate also. We called for an ambulance. Rechecked blood pressure after 5 minutes and it was 187/120 which was even higher than initially. Patient was transmitted to the hospital. No additional report on current status.


VAERS ID: 1870410 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Unknown  
Location: Unknown  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Underdose
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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt age 12 received the Pfizer vaccine appropriate for ages 5-11. Pt remained in observation and left with guardian


VAERS ID: 1870411 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8030 / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Headache, Lethargy, Pain
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (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: April 15 2021 pfizer
Other Medications: none
Current Illness: none
Preexisting Conditions: occasional migraine headches
Allergies: none
Diagnostic Lab Data: nonne
CDC Split Type:

Write-up: next morning after shot, extreme lethargy and body and head ache pains, which persisted thru day and elevated during evening hours.


VAERS ID: 1870414 (history)  
Form: Version 2.0  
Age: 8.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: No adverse event, Product preparation issue
SMQs:, Medication errors (broad)

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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE KNOWN
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: THIS REPORT IS FOR AN ADMINISTRATION ERROR, NOT AN ADVERSE EVENT. PT RECEIVED A LOWER VACCINE DOSE DUE TO DILUENT ADDITION ERROR. NO ADVERESE EFFECTS NOTED DURING OBSERVATION PERIOD OR TODAY UPON FOLLOW UP PER PT MOTHER.


VAERS ID: 1870415 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-11-03
Onset:2021-11-15
   Days after vaccination:12
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 320308D / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Miliaria, Rash
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: no
Current Illness: no covid back in july 2021
Preexisting Conditions:
Allergies: no allergies
Diagnostic Lab Data: no
CDC Split Type:

Write-up: pt woke up with a heat rash with white bumps on face after 2 days getting vaccinated. pt got rash again 10 days after vaccination.


VAERS ID: 1870417 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FF2589 / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Feeling hot, Flushing, Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: BENZTROPINE, BUSPIRONE, CETIRIZINE, BENADRYL, DIVALPROEX, FLUOXETINE, QUANFACINE, KLONOIN, METHYLPHENIDATE, MONTELUKAST, OMEPRAZOLE, POLYETHYLENE GLYCOL, QUETIAPINE, SEROQUEL, SUCRALFATE, TRAZODONE
Current Illness: NONE
Preexisting Conditions: AUSTISM, ASTHMA, INTERMITTENT EXPLOSIVE DISORDER, REFLUX, DEPRESSION, ADHD, ANXIETY, ALLERGIC RHINITIS
Allergies: PENICILLIN, BACTRIM
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Patient received his second COVID 19 vaccine at 1533. At 1550, he developed flushing on his ears and a feeling of warmth in his body. His temperature was 37 degrees. His BP was 110/62, HR 78 and respirations 24 and unlabored. I reported his symptoms to Dr. She assessed him and noted two hives on his neck and two on his chest. He had no respiratory distress or wheezing. At 1554, EpiPen 0.3 mg was administered into his left thigh. At 1559, his BP was 112/58, HR 84 and respirations 22. His SaO2 was 99% on room air. At 1605, two hives remained, the flushing on his ears improved and the ER was notified. At 1612, he was transferred to the ER via wheelchair.


VAERS ID: 1870420 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Female  
Location: Vermont  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8027 / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Feeling abnormal
SMQs:, Dementia (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: Loratadine, Flovent
Current Illness: None
Preexisting Conditions: Asthma, pet and dust allergies
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Sensation in face and mouth like eating something sour, continued for hours, particularly on left side. Still mild as of submitting this form


VAERS ID: 1870444 (history)  
Form: Version 2.0  
Age: 34.0  
Sex: Female  
Location: New York  
Vaccinated:2021-11-13
Onset:2021-11-15
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Heavy menstrual bleeding
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow)

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: None.
Current Illness: None.
Preexisting Conditions: None.
Allergies: None.
Diagnostic Lab Data:
CDC Split Type:

Write-up: On November 13 I got vaccinated at 2 pm. On November 14, my period started normally. On November 15, I was bleeding abundantly and had a lot of blood clots. Something that has never happened to me before. I think it''s a side effect of the vaccine because it''s really weird.


VAERS ID: 1870453 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FG3527 / 3 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Adverse reaction
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Benadryl and hydrocortisone cream


VAERS ID: 1870648 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cold sweat, Loss of consciousness, Pallor
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none reported by mom
Current Illness: none reported by mom
Preexisting Conditions: none reported by mom
Allergies: none reported by mom
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient passed out approximately 10 mins after receiving 1st Pfizer Pediatric vaccine. Patient regained consciousness within 45 seconds, appeared clammy and pale, ice packs were applied to forehead and neck.


VAERS ID: 1870651 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Female  
Location: Utah  
Vaccinated:2021-11-14
Onset:2021-11-15
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8028 / 3 RA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 2 - / SYR
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3247 / 1 - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dyspnoea, Loss of consciousness, Palpitations
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (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: Trentinoine topical cream
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Symptomatic palpitation, shortness of breath, passing out at 5:05 am in the morning. Heart continues to race and then slowdown all today, current time is 6:05 pm.


VAERS ID: 1870675 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-11-15
Onset:2021-11-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 213D21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cold sweat, Hyperhidrosis, Loss of consciousness, Pallor, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

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: non im aware of
Current Illness: none im aware of
Preexisting Conditions: none im aware of
Allergies: none im aware of
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient sat down and was very out of it and swaying. pale and clammy very sweaty, passed out put him on the floor and put cold bottle on face his pulse remained steady. finally was coherent did call emergency number the ambulance came and he vomited before he left the building very non coherent at first


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