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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1371611



Case Details

VAERS ID: 1371611 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-06-03
Onset:2021-06-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0180 / 1 LA / IM

Administered by: Pharmacy       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: Unknown.
Current Illness: Unknown.
Preexisting Conditions: Unknown
Allergies: Amoxicillin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Vaccine was diluted w smaller than recommended volume of diluent resulting in a more concentrated dose administered.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1371611


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