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

This is VAERS ID 1434504



Case Details

VAERS ID: 1434504 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-06-21
Onset:2021-06-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 034C21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Extra dose administered, Malaise
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: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Had completed two doses of Pfizer vaccine but did not disclose to vaccination staff therefore was given a dose of Moderna vaccine. Reported that he did not feel well the next day after receiving the Moderna dose, was in bed for the entire day, which resolved the next day.


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