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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1368872



Case Details

VAERS ID: 1368872 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-06-01
Onset:2021-06-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027C21A / 2 LA / IM

Administered by: Unknown       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: Co-Lead Ancillary alerted Lead RN over waki taki at 13:25 that a mother and her minor daughter were on site so the minor could receive her 2nd dose of Moderna vaccine. The minor had received her first Moderna dose on 04/20/21 at another facility. Lead RN check-in RN to assist mother and minor once they had completed the check-in process and came upstairs to be vaccinated. Once upstairs, Check-in RN escorted minor and mother to an RN vaccination station so the minor could receive the vaccine. RN performed verification procedures regarding minors who are accompanied by a parent and reviewed the minor?s vaccination card to confirm the minor had been vaccinated inappropriately on 04/20/21. The minor had received Moderna dose #1 COVID vaccine, Lot# 001C21A. Lead RN confirmed it was appropriate for the minor to receive the 2nd dose of Moderna to complete the series, per CDC Guidelines. RN vaccinator educated the minor and her mother regarding Moderna''s suggested application of 18 years and older only. RN vaccinator then confirmed with the minor and mother that the minor had not experienced any type of adverse reaction to the first dose. The minor and her mother also denied the minor having any significant medical history, current medications, supplements, or allergies. The minor and mother verbalized understanding and expressed a desire to proceed with the second vaccination. RN vaccinator reinforced to the minor and her mother to please stay for the full 15 minutes in the observation area, and explained that both a VAERS and VERP report would be submitted to document the incident of the minor receiving Moderna as an unauthorized age group. The minor received Moderna vaccination #2 lot# 027C21A at 13:39. Minor and mother proceeded to the observation room at 13:43. Lead RN checked on minor client in the observation room at 14:00 where both the minor and her mother denied any side effects and left the observation room. Lead RN observed the minor was ambulating independently with a steady, even gait, with when exiting with her mother.


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