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From the 9/3/2021 release of VAERS data:

This is VAERS ID 1371718



Case Details

VAERS ID: 1371718 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Male  
Location: Arkansas  
Vaccinated:2021-06-03
Onset:2021-06-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 207A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Fall, Head injury, Loss of consciousness
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), Accidents and injuries (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? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: syncope
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient received a dose of the Jassen covid vaccine and was sitting in the waiting room for his 15 minutes of observation. After about 10 minutes he passed out and fell out of his chair bumping his head on the way down.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1371718


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