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

This is VAERS ID 1328268



Case Details

VAERS ID: 1328268 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Male  
Location: Arizona  
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 (JANSSEN)) / JANSSEN 041A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Loss of consciousness, Pallor, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (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: Vasovagal history after vaccine or blood draw
Other Medications: PT states none
Current Illness: PT states none
Preexisting Conditions: PT states none
Allergies: PT states none
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 24 male PT experienced syncopal episode approx 1 minute after receiving 1st dose Janssen COVID19 vaccine 041A21A IM Left deltoid which resulted in approx 5 seconds of unconsciousness. PT helped to floor by on site staff and placed in trendelenburg position. Staff called 911, obtained verbal consent for assessment, baseline vitals and demographics obtained. BP 110/70, SPO2 99%RA, Pulse 76 regular @ radial, skin CTC pale, cool, dry, and not trauma observed or stated. PT denies past medical history, denies medication use or non-compliance and states he has had 48oz of water in last 24hrs. PT denies any further medical complaint. Janssen assumed PT care at 1615. END REPORT


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