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VAERS Report 2095509

Case Report Section

Vaer Report Details

Age: 52 years old

Gender: Female

State: Puerto Rico

Patient Died?
No
Vaccine information

Name: COVID19 (COVID19 (MODERNA))

Type: Coronavirus 2019 vaccine

Manufacturer: MODERNA

Lot: unknown


Date report was received
2022-02-08
Date form completed
Date Vaccinated
2021-06-17
Date of Onset
0
Number of days (onset date – vaccination date)
0
Adverse Event Description

na

Lab Data
na
List of symptoms
Patient Died?
No
Date Died
NA
Birth defect
false
Vaccine Administered By:
Unknown
Vaccine Purchased By:
Unknown
Patient visit ER?
No
Patient Hospitalized?
No
Stay in hospital
No
Days in hospital
Unspecified
Permanent disability?
No
Allergies:
na
Current Illness
na