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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1085647

Case Details

VAERS ID: 1085647 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: New York  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1805022 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Anxiety, Asthenia, Dizziness, Electrocardiogram abnormal, Hypotension
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data: Paramedic Reformat obtained vitals and noted patient to be hypotensive and anxious. She reports that she feels weak and dizzy. Repeat vitals and ecg done and pt still hypotensive. 12 lead shows irregularities. Pt recommended to be transported to hospital for eval. Pt agrees and IV access obtained. Saline bolus hung on patient. Pt care transferred for transport. Pt was transported to hospital.
CDC Split Type:

Write-up: Patient received vaccine at approximately 10:50 AM. She proceeded to the observation area where she began to feel light-headed. On-site EMS from was summoned. EMS placed the woman on their gurney and began assessment (vitals and EKG). A copy of the PCR has been requested, but may not be available.

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