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

This is VAERS ID 1388374



Case Details

VAERS ID: 1388374 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 014C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Inappropriate schedule of product administration
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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: Pineapple
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Patient was given second dose of Moderna vaccine at a 21 day interval not 28


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