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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1152266

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Case Details

VAERS ID: 1152266 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: North Dakota  
Vaccinated:2021-03-11
Onset:2021-03-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001B21A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chills, Cough, Fatigue, Product administered to patient of inappropriate age, Pulmonary congestion, Pyrexia, SARS-CoV-2 test negative
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (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: Paroxetine and oral birth control (not sure which ones)
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Patient was tested for covid on 3/22/21 and 3/25/21 due to viral illness she thinks she caught while working at daycare center. Her symptoms were chest congestion, cough with lots of phlegm and low grade temp. She was also tested for covid on 3/26/21 at a healthcare facility where she works. All 3 tests were negative.
CDC Split Type:

Write-up: 16 year old was vaccinated with Moderna on 3/11/21. Error was found on 3/26/21 by staff reviewing registration list for upcoming covid vaccine clinics. Spoke with patient and her mother on 3/30/21 to report what happened. Patient reported feeling very tired starting on the evening of 3/11/21 and continued until 3/12/21 around bedtime. Also had chills that started on 3/11/21 in the evening and lasted until 5pm on 3/12/21. Denies any other symptoms or problems.


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