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

This is VAERS ID 1053176

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Case Details

VAERS ID: 1053176 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-02-08
Onset:2021-02-10
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Haemorrhage, Intensive care, Reaction to preservatives, Thrombocytopenia
SMQs:, Haematopoietic thrombocytopenia (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
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:
Current Illness:
Preexisting Conditions: GERD, COPD, type 2 diabetes
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: severe reaction within 48 hours of the vaccine , sent to the hospital with uncontrollable bleeding, in ICU with thrombocytopenia


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