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

This is VAERS ID 930567

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Case Details

VAERS ID: 930567 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
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 041L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Immediate post-injection reaction, Product administered to patient of inappropriate age, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Medication errors (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: patient had a syncopal episode at time of injection. lasted <10 seconds. Also reporting due to patient age 17 years old. Patient stated she thought she could take vaccine so she registered for it.


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