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

This is VAERS ID 1454556

Case Details

VAERS ID: 1454556 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Male  
Location: Illinois  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Pharmacy       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
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: N/A
Current Illness:
Preexisting Conditions:
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s mother misinformed us about patient''s age. Listed on form as incorrect DOB when actual birthday is exact date. Mother verbally confirmed the incorrect birthday several times during the visit. Issue was discovered at the time of billing when the insurance informed us of the exact date birthday. When we called the mother back to confirm which is correct, she admitted to putting the wrong birthdate on the form. We informed her that the patient cannot get a follow up immunization until after the actual date of birth.

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