6FN-14581-05898

3 vaccinations 8 coded responses 20 check-ins 8 free-text entries 2 call cases

Sex: Male
Age at first dose: 66+
ZIP prefix: 856 / AZ
Registered: 2021-02-12

Relationship: Self
Race: White
Ethnicity: Hispanic or Latino

Timeline

Registration Vaccinations Survey responses Call reports Cases without a report Call attempts Call successful Pregnancy survey

2021-02-11
Dose 1 — Moderna
2021-02-12
Registered in v-safe
2021-02-13
Health check-in — days 1–6 daily, dose 1
Feeling: Good · Site: Pain, Swelling · Headache, Nausea

Adult check-in
2021-02-14
Survey response — days 1–6 daily, dose 1
MedDRA: No adverse event — Feeling: Fair · Fever · Chills, Headache, Diarrhea

Free text: No other problems

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-02-15
Health check-in — days 1–6 daily, dose 1
Feeling: Good · Chills, Headache

Adult check-in
2021-02-16
Health check-in — days 1–6 daily, dose 1
Feeling: Good · Headache

Adult check-in
2021-02-18
Health check-in — day 7, dose 1
Feeling: Good · None

Adult check-in
2021-02-25
Survey response — day 14, dose 1
MedDRA: Chills, Headache — Feeling: Fair

Free text: Chills and headache that wont go away

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-03-05
Health check-in — day 21, dose 1
Feeling: Good

Adult check-in
2021-03-11
Health check-in — day 28, dose 1
Feeling: Good

Adult check-in
2021-03-14
Dose 2 — Moderna
2021-03-18
Health check-in — days 1–6 daily, dose 2
Feeling: Good · Site: Pain · Chills, Headache, Joint pains, Muscle or body aches, Fatigue or tiredness

Adult check-in
2021-03-19
Health check-in — days 1–6 daily, dose 2
Feeling: Good · Site: Pain, Swelling · Fever · Chills, Headache, Joint pains, Muscle or body aches, Fatigue or tiredness

Adult check-in
2021-03-20
Health check-in — days 1–6 daily, dose 2
Feeling: Good · Site: Pain · Fever · Chills, Headache, Muscle or body aches, Fatigue or tiredness

Adult check-in
2021-03-21
Health check-in — day 7, dose 2
Feeling: Good · Fever · Chills, Headache, Joint pains, Muscle or body aches

Adult check-in
2021-03-28
Survey response — day 14, dose 2
MedDRA: Chills, Headache — Feeling: Good

Free text: Just having chills and a headache otherwise Im alright. I have been drinking lots of Pedialyte.

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-04-04
Survey response — day 21, dose 2
MedDRA: Chills — Feeling: Good

Free text: Chills

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-04-11
Health check-in — day 28, dose 2
Feeling: Good

Adult check-in
2021-04-25
Survey response — day 42, dose 2
MedDRA: Chills, Headache, Medical counselling, Office visit, Sinusitis — Feeling: Fair · Be unable to work, Be unable to do your normal daily activities, Get care from a doctor or other healthcare professional · Telehealth, virtual health, or email health consultation

Free text: Symptoms: Developed a serious sinus infection and headaches, along with chills. Was told that I may have COVID-19 but refused to accept their decision about diagnosis. Contacted a nurse through the VA nurse line and was informed that their diagnosis wrong. · Healthcare visit (other): Actual doctor visit which changed immediately to virtual from my vehicle. I didnt appreciate being examined outside and displayed in front of the other patients coming in to see the doctors.

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-04-25
Report sent to call center — day 42, dose 2
Be unable to work · Be unable to do your normal daily activities · Get care from a doctor or other healthcare professional

1 call case(s)
2021-06-13
Survey response — 3 months, dose 2
MedDRA: Hospitalisation, Pre-existing disease, Sepsis — Feeling: Good · Be unable to work or attend school, Be unable to do your normal daily activities, Get care from a doctor or other healthcare professional · Telehealth, virtual health, or email health consultation

Free text: On June 2, I was at a urologist appointment and they gave me a very deadly infection which is Sepsis and E-coli and was hospitalized for two days

MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
2021-06-13
Report sent to call center — 3 months, dose 2
Be unable to work or attend school · Be unable to do your normal daily activities · Get care from a doctor or other healthcare pr

1 call case(s)
2021-06-18
Call 1 — Left Voicemail
2021-06-18
Call successful
Participant prefers to complete VAERS report online
2021-09-13
Dose 3 — Moderna
Co-administered: Other
2021-09-13
Health check-in — 6 months, dose 2
Feeling: Good

Adult check-in
2021-10-26
Survey response — day 42, dose 3
MedDRA: Escherichia infection, Hospitalisation, Sepsis — Feeling: Good · Be unable to work or attend school

Free text: Was in the hospital for Sepsis and E-coli on June 3, because of medical negligence

MedDRA releases: 2024-11 · check-in free text available
2021-12-13
Survey response — 3 months, dose 3
MedDRA: Bronchitis, Condition aggravated, Pre-existing disease — Feeling: Poor · Be unable to work or attend school

Free text: Serious infection of chronic bronchitis since the beginning of November 1st and haven't been able to get rid of the bronchitis

MedDRA releases: 2024-11 · check-in free text available

Vaccinations

Dose	Date	Manufacturer	Co-administered
1	2021-02-11	Moderna
2	2021-03-14	Moderna
3	2021-09-13	Moderna	Other

Call center

2 call center cases

2 successful

See the call center timeline

Free text

Release 4 — days 1–6 daily, dose 1

2021-02-14

Systemic reaction (other): No other problems

Release 4 — day 14, dose 1

2021-02-25

Symptoms: Chills and headache that wont go away

Release 6 — day 14, dose 2

2021-03-28

Symptoms: Just having chills and a headache otherwise Im alright. I have been drinking lots of Pedialyte.

Release 6 — day 21, dose 2

2021-04-04

Symptoms: Chills

Release 7 — day 42, dose 2

2021-04-25

Symptoms: Developed a serious sinus infection and headaches, along with chills. Was told that I may have COVID-19 but refused to accept their decision about diagnosis. Contacted a nurse through the VA nurse line and was informed that their diagnosis wrong.

Healthcare visit (other): Actual doctor visit which changed immediately to virtual from my vehicle. I didnt appreciate being examined outside and displayed in front of the other patients coming in to see the doctors.

Release 9 — 3 months, dose 2

2021-06-13

Symptoms: On June 2, I was at a urologist appointment and they gave me a very deadly infection which is Sepsis and E-coli and was hospitalized for two days

Release 10 — day 42, dose 3

2021-10-26

Symptoms: Was in the hospital for Sepsis and E-coli on June 3, because of medical negligence

Release 10 — 3 months, dose 3

2021-12-13

Symptoms: Serious infection of chronic bronchitis since the beginning of November 1st and haven't been able to get rid of the bronchitis

Each entry is dated by the survey it was written in (the CDC re-sent the releases with survey dates in 2025); click a date to see that survey response. The CDC cut some text off at about 250 characters: symptoms in every release, and the other two fields in releases 9-12. Those entries are marked "cut off by CDC".

MedDRA terms by release

Field	Preferred term	2021-09	2023-04	2024-11
HCVO	Medical counselling	✓	✓	✓
SD	Bronchitis	·	·	✓
SD	Chills	✓	✓	✓
SD	Condition aggravated	·	·	✓
SD	Escherichia infection	·	·	✓
SD	Headache	✓	✓	✓
SD	Hospitalisation	✓	✓	✓
SD	Medical counselling	✓	✓	✓
SD	Office visit	✓	✓	✓
SD	Pre-existing disease	✓	✓	✓
SD	Sepsis	✓	✓	✓
SD	Sinusitis	✓	✓	✓
SRO	No adverse event	✓	✓	✓

✓ active code · ○ coded but marked inactive · blank = not in that release