VAERS ID: 1317696

AGE: 16| SEX: F|STATE: NC

Description

Vaccine administration error: Recipient received first and second dose of Moderna Vaccine at the age of 16. First dose was given on 04/06/2021. Second dose was given on 05/04/2021. She reports not experiencing any adverse symptoms and/or side effects from either vaccine.

Symptoms

No adverse event, Product administered to patient of inappropriate age

Vaccines

VAX DATE: 04-06-2021| ONSET DATE: 04-06-2021| DAYS TO ONSET: 0
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (MODERNA)) 1 COVID19 MODERNA 019B21A IM LA
COVID19 (COVID19 (MODERNA)) 2 COVID19 MODERNA 004C21A IM LA

RECVDATE:05-14-2021
RPT_DATE:
CAGE_YR:16
CAGE_MO:
DIED:U
DATEDIED:
L_THREAT:U
ER_VISIT:U
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:Y
LAB_DATA:n/a
V_ADMINBY:PVT
OTHER_MEDS:
CUR_ILL:
HISTORY:Celiac Disease
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:2
TODAYS_DATE:05-14-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:NKA
V_FUNDBY:

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