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

This is VAERS ID 1474628



Case Details

VAERS ID: 1474628 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-07-15
Onset:2021-07-15
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 021C21A / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Extra dose administered, Incorrect product formulation administered, No adverse event
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: No adverse effects noted at time of submission. Patient received complete series of Pfizer vaccine previously, then received Moderna vaccine today (3rd dose of mRNA). Patient did not disclose previous vaccinations, was discovered after the fact. Pfizer dose #1 on 4/30/21, Pfizer dose #2 on 6/24/21, Moderna dose #1 7/15/21.


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