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From the 9/3/2021 release of VAERS data:

This is VAERS ID 1440685



Case Details

VAERS ID: 1440685 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-03-08
Onset:2021-07-01
   Days after vaccination:115
Submitted: 0000-00-00
Entered: 2021-07-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004C21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Interchange of vaccine products
SMQs:, Medication errors (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: The patient scheduled himself for his first dose of Moderna. On 03/08/2021 at another vaccine site. Patient did not tell the staff that he had a vaccine. Informed us this was his first vaccine.


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