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

This is VAERS ID 1392435



Case Details

VAERS ID: 1392435 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-06-03
Onset:2021-06-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0217 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect product formulation administered, Product use issue, Wrong device used
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The vaccine was mixed using a multi-dose vial of diluent. The diluent vial was punctured twice and used to mix two vials of vaccine. The dose was given IM and a 5/8 inch needle may have been used.


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