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

This is VAERS ID 1779887

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Case Details

VAERS ID: 1779887 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-10-05
Onset:2021-10-05
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040C21A / 3 - / IM

Administered by: Work       Purchased by: ?
Symptoms: No adverse event, Product storage error
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: Unknown.
Current Illness:
Preexisting Conditions: Hypertension, Arthritis, Dyslipidemia.
Allergies: Allergy-Morphine.
Diagnostic Lab Data: This was reported to the manufacturer Moderna for a recommendation if the dose should be repeated. Moderna case #CEA0843 There response: Thank you for your unsolicited inquiry: Pharmacist states that 4 patients received their 3rd doses of the Moderna Covid-19 Vaccine 33 days after the vial was moved to refrigeration. She wants to know how to proceed. Lot number(s): 040C21A. Number of doses/vials: 1 vial/4 doses. Date the vial was initially stored in the refrigerator: 2Sep2021. Date(s) of administration of vaccine: 5Oct2021. Did the vial undergo any temperature excursions? No Our team can conduct an analysis to determine if the vaccine administered past the expiry date provided the necessary protection against a COVID-19 infection. Due to the nature of your event, a LOT assessment will be conducted to determine the activity level of the vaccine. This assessment can take 8 to 10 business days. Your case number is CEA-0843. Following the conclusion of that assessment you will be contacted and provided with a product stability determination and instructions.
CDC Split Type:

Write-up: The vaccine was administered 3 days after the beyond use date. The dose was administered on 10/5/2021 when the beyond use date was 10/2/2021. The expiration date of the vial was 10/31/21. The expiration date was used instead of the beyond use date. No outcome or adverse event occurred at this time


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