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From the 1/7/2022 release of VAERS data:

This is VAERS ID 930541

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Case Details

VAERS ID: 930541 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: No adverse event, Product administered to patient of inappropriate age
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: unknown
Preexisting Conditions: hypertension, obese
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: no side effects or symptoms at time of dose or observation time. reporting because of patient age


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