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VAERS Report 2095572

Case Report Section

Vaer Report Details

Age: 75 years old

Gender: Male

State: Michigan

Patient Died?
No
Vaccine information

Name: COVID19 (COVID19 (MODERNA))

Type: Coronavirus 2019 vaccine

Manufacturer: MODERNA

Lot: 040b21a


Date report was received
2022-02-08
Date form completed
Date Vaccinated
2021-04-16
Date of Onset
298
Number of days (onset date – vaccination date)
298
Adverse Event Description

asymptomatic

Lab Data
na
List of symptoms
unevaluable event
Patient Died?
No
Date Died
NA
Birth defect
false
Vaccine Administered By:
Public
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