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From the 5/7/2021 release of VAERS data:

This is VAERS ID 1130843



Case Details

VAERS ID: 1130843 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-03-24
Onset:2021-03-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808609 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Extra dose administered, No adverse event
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: Patient stated that he wanted a vaccine today while staff were in the unit. He denied receiving it prior. He was given the vaccine and upon documenting it was discovered that he receive the Modern vaccine 1st dose on 2/2/21 and 2nd dose on 3/2/21. Today he received Jannsen dose. He has no adverse effects and no complaints.


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