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This is VAERS ID 1378004

History of Changes from the VAERS Wayback Machine

First Appeared on 6/11/2021

VAERS ID: 1378004
VAERS Form:2
Age:78.0
Sex:Male
Location:Missouri
Vaccinated:2021-06-04
Onset:2021-06-04
Submitted:0000-00-00
Entered:2021-06-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK - / -

Administered by: Pharmacy      Purchased by: ??
Symptoms: Wrong product administered

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient thought they were receiving Moderna Vaccine, received Janssen vaccine instread.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1378004&WAYBACKHISTORY=ON


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