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

This is VAERS ID 1330954



Case Details

VAERS ID: 1330954 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Male  
Location: New York  
Vaccinated:2021-05-19
Onset:2021-05-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EW0183 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Fall, Product administered to patient of inappropriate age, Skin abrasion, Skin laceration, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Medication errors (narrow), 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
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Vital signs: BP 100/80, Pulse 92, Resp 18, SaO2 98%. Staff recommends ambulance transport to Hospital, parents state will take patient to Urgent Care via personal vehicle.
CDC Split Type:

Write-up: Brief syncopal episode, fell from chair, struck head on floor, suffered small laceration and abrasion to left eyebrow.


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