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

This is VAERS ID 1328058



Case Details

VAERS ID: 1328058 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Male  
Location: California  
Vaccinated:2021-05-18
Onset:2021-05-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Fall, Head injury, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

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? No
Previous Vaccinations:
Other Medications: None stated except for 2nd dose of Moderna Covid-19 vaccine (lot 038C21A, exp 10/27/21)
Current Illness: Lack of sleep and hydration.
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient was given injection with no issues; spent a few minutes post injection speaking to patient about the potential side effects. Encouraged him to stay hydrated and to utilize Tylenol if fever, pain, or aches. Patient was alert and oriented when he left the vaccination room. After sanitizing the room for the next member, preparing the next member''s shot, came out of the room to announce the next member and found the original patient face down on the floor of the warehouse. Witnesses stated he had fell to his knees from a sitting position and then hit his head on the floor with no more then 2 minutes going by (most likely less then 1 minute). Had the patient lay on the ground with legs elevated while he came to. Offered patient water and ice pack. Patient was able to call his parents, which I stayed by his side, until they arrived.


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