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This is VAERS ID 1775177

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/15/2021

VAERS ID: 1775177
VAERS Form:2
Age:13.0
Sex:Female
Location:California
Vaccinated:2021-10-09
Onset:2021-10-09
Submitted:0000-00-00
Entered:2021-10-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 053E21A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: No adverse event, Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None stated.
Current Illness: none stated
Preexisting Conditions: None stated
Allergies: penicillin V
Diagnostic Lab Data: n/a
CDC 'Split Type':

Write-up: Patient was given 1st dose of Moderna vaccine, Lvn supervisor Monitored patient for 45 minutes after injection in lobby. no side effects noted. Supervisor informed mother of vaccine administration and will follow up in the upcoming days and set up a follow up appt. with PCP. Informed mother if patient begins to have any adverse reactions to the vaccine do not hesitate to go to urgent care or local hospital.

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