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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1376014



Case Details

VAERS ID: 1376014 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0180 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Loss of consciousness, Tremor
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), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (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:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: asthma
Allergies: no
Diagnostic Lab Data:
CDC Split Type:

Write-up: after dose was administered by began to shake and then lost consciousness, patient was laid on floor were he immediately regained consciousness, when he felt up to it he was sat in his chair, given energy drink and water and instructed to place his head between his knees if he felt light headed, he was then monitored for the next 30 mins without further incident


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