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This is VAERS ID 926918

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 926918
VAERS Form:2
Age:17.0
Sex:Female
Location:Missouri
Vaccinated:2021-01-05
Onset:2021-01-05
Submitted:0000-00-00
Entered:2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Pharmacy      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? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: No adverse event noted. Patient is 17 years old (17.5) and the approved age for this vaccine is 18. This was inadvertently missed at check-in. Patient suffered no untoward effects


Changed on 5/7/2021

VAERS ID: 926918 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:Missouri
Vaccinated:2021-01-05
Onset:2021-01-05
Submitted:0000-00-00
Entered:2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Pharmacy      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? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions:
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: No adverse event noted. Patient is 17 years old (17.5) and the approved age for this vaccine is 18. This was inadvertently missed at check-in. Patient suffered no untoward effects


Changed on 5/21/2021

VAERS ID: 926918 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:Missouri
Vaccinated:2021-01-05
Onset:2021-01-05
Submitted:0000-00-00
Entered:2021-01-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Pharmacy      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? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness:
Preexisting Conditions:
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: No adverse event noted. Patient is 17 years old (17.5) and the approved age for this vaccine is 18. This was inadvertently missed at check-in. Patient suffered no untoward effects

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