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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1322111



Case Details

VAERS ID: 1322111 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: California  
Vaccinated:2021-05-04
Onset:2021-05-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA O30B21A / 1 - / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Complication associated with device, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: lipitor, lasix, zyrtec,insulin,metoprolol, phoslo, hydraziline
Current Illness: Covid+ 2/10/21 requiring hosp, neg Covid pcr 3/17, 4/5. positive covid 5/12(Ct 40.40 Covid + 5/16 (Ct 38.5)
Preexisting Conditions: hemodialysis, diabetes, ESRD, MGUS
Allergies: n/a
Diagnostic Lab Data: positive covid pcr 5/12,5/17
CDC Split Type:

Write-up: hospitalized 5/12 because unable to dialyze in his unit


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