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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1750423

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Case Details

VAERS ID: 1750423 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-09-27
Onset:2021-09-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017F21A / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Extra dose administered, No adverse event
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: N/A
Current Illness: Not illnesses
Preexisting Conditions: No outstanding health conditions
Allergies: No allergies
Diagnostic Lab Data: N/A - no adverse reactions
CDC Split Type:

Write-up: No adverse reaction - third dose (full dose of 0.5ml) was administered without proper implications (only risk factor was age above $g65).


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