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

This is VAERS ID 1381807



Case Details

VAERS ID: 1381807 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-04-13
Onset:2021-06-04
   Days after vaccination:52
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, Interchange of vaccine products
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: no
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient received first dose of COVID-19 vaccine (Moderna) on 4/13/21. The second dose of COVID-19 vaccine was Pfizer-BioNTech, which was administered on 6/4/21.


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