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

This is VAERS ID 1771143

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Case Details

VAERS ID: 1771143 (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, Product administered to patient of inappropriate age
SMQs:, Extravasation events (injections, infusions and implants) (broad), Tendinopathies and ligament disorders (broad), 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: Site: Pain at Injection Site-Mild, Systemic: Sore arm for 24 hours and patient has been given ibuprofen for pain-Mild, Error: Patient Too Young for Vaccine Administered-, Additional Details: Pharmacist contacted patients family regarding the wrong administration event. Mom wanted to talk to CVS legal immunization team regarding the event and also wanted to inform her employer as well. the error could have been prevented if we have working laptops at the clinic site. patient has been requested not to get the second dose of vaccine untill further notice.


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