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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1367827



Case Details

VAERS ID: 1367827 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-06-01
Onset:2021-06-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Eye movement disorder, Loss of consciousness, Unresponsive to stimuli
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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type: 132173124

Write-up: At 12-00pm the pharmacist gave patient a J & J Covid Vaccine. He asked him to sit down for 15 minutes. At approximately 12-10PM Patient yelled for assistance. At the time the pharmacist ran over to the chair. Patient siaf that he was going to pass out. His eyes rolled back and it seemed like a seizure, at that point he began to pass out. The pharmacist assisted him to the floor. He was unresponsive on the floor for 10 seconds. After 10 seconds he regained consiouness. He said he felt fine. We called the ambulance. They came 15 minutes later. The pharmacist did his vitals pulse: 60 respirations:16 blood pressure 115/70. At that time the ambulance came and assisted him to the hospital.


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