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

This is VAERS ID 934091

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Case Details

VAERS ID: 934091 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-01-09
Onset:2021-01-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: 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: n/a
Current Illness: none
Preexisting Conditions: none reported
Allergies: NKDA
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient was vaccinated but was out of out of recommended age range. Pharmacist did not recognize error until after injection was complete. Patient did not have any post-injection reaction.


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