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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1771142

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Case Details

VAERS ID: 1771142 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-10-05
Onset:2021-10-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050E21A / 1 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Injection site pain, Pain in extremity
SMQs:, Extravasation events (injections, infusions and implants) (broad), Tendinopathies and ligament disorders (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: Site: Pain at Injection Site-Mild, Systemic: Sore Arm for 1 day as per mom and pt has taken ibuprofen for 24 hours.-Mild, Error: Patient Too Young for Vaccine Administered-, Additional Details: Sore Arm for 1 day as per mom and pt has taken ibuprofen for 24 hours. Pharmacist has requested the immunization team to contact the patients family regarding any further notice. patient has been waiting for the call from pharmacy in order to hear anything in details. The error could have been prevented if laptops were present during the clinic and woking. we could not type a prescription as system was automatically rejecting due to age limit.


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