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

This is VAERS ID 1430855



Case Details

VAERS ID: 1430855 (history)  
Form: Version 2.0  
Age: 25.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-04-14
Onset:2021-06-26
   Days after vaccination:73
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026B21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: SARS-CoV-2 test
SMQs:, COVID-19 (broad)

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: Individual RNA PCR at Clinic, a pharmacy within a Pharmacy. Case investigation has not been completed at the time of this note.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1430855


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