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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1331241



Case Details

VAERS ID: 1331241 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-05-19
Onset:2021-05-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0177 / 1 RA / IM

Administered by: Public       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? 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: Parent (father) wrote birthdate of 07/20/2008 on the vaccine consent form. When the clinical provider repeated the birthday for confirmation, the child said it was incorrect. The father confirmed that it WAS correct. The vaccinator proceeded with the vaccine administration to the child, based on the father''s confirmation. Post-vaccine, the vaccinator approached this Lead RN and expressed concern about the actual age of the patient. This Lead RN looked up the patient and confirmed that the birthday was actually 07/20/2009, placing the child at age 11. The patient was kept under observation for 15 minutes. No adverse outcome, side effects, complaints noted. The parent was approached and informed that a second dose would not be provided to the patient, a report would be filled and would be updated. The parent did not deny placing the wrong birthday on paperwork. The parent expressed that the goal was to have the child vaccinator prior to a trip.


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