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From the 1/14/2022 release of VAERS data:

This is VAERS ID 910017

Government Disclaimer on use of this data



Case Details

VAERS ID: 910017 (history)  
Form: Version 1.0  
Age: 73.0  
Sex: Male  
Location: Unknown  
Vaccinated:2020-12-22
Onset:2020-12-23
   Days after vaccination:1
Submitted: 2020-12-23
   Days after onset:0
Entered: 2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other       Purchased by: Other
Symptoms: Unevaluable event
SMQs:

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: Treatment dugs:


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=910017


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