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

This is VAERS ID 1378021



Case Details

VAERS ID: 1378021 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 045B21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Product storage error
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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Vaccine was drawn up at 9:30 AM on 06/03/2021 and was administered to patient at 04:25 PM on 06/04/2021. Reached out to patient several times, phone number out of service. Contacted manufacturer and CDC for recommendation. If able to get into contact with patient, will recommend patient to come in and to get a re-dose of the vaccine in the opposite arm to ensure proper efficacy.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1378021


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