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

This is VAERS ID 1375691

Case Details

VAERS ID: 1375691 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Michigan  
Submitted: 0000-00-00
Entered: 2021-06-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 041A214 / UNK - / -

Administered by: Other       Purchased by: ?
Symptoms: Eye disorder, Feeling hot, Headache, Pain in extremity
SMQs:, Corneal disorders (broad), Retinal disorders (broad), Tendinopathies and ligament disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Diagnostic Lab Data:
CDC Split Type: USJNJFOC20210604965

Write-up: WARM ARM; EYES WERE BOTHERING; LEFT ARM PAIN THAT WENT UP TO SHOULDER TO BACK AND DOWN TO HAND; HEADACHE; This spontaneous report received from a patient concerned an 85 year old female. The patient''s height, and weight were not reported. No past medical history or concurrent conditions were reported. The patient received covid-19 vaccine ad26.cov2.s (suspension for injection, route of admin not reported, batch number: 041A214 expiry: UNKNOWN) dose was not reported, administered on 01-JUN-2021 for prophylactic vaccination. No concomitant medications were reported. On JUN-2021, the subject experienced warm arm. On JUN-2021, the subject experienced eyes were bothering. On JUN-2021, the subject experienced left arm pain that went up to shoulder to back and down to hand. On JUN-2021, the subject experienced headache. The action taken with covid-19 vaccine ad26.cov2.s was not applicable. The outcome of the headache, left arm pain that went up to shoulder to back and down to hand, warm arm and eyes were bothering was not reported. This report was non-serious.

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