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

This is VAERS ID 1382051



Case Details

VAERS ID: 1382051 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0217 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Head injury, Hypoxia, Seizure, Vomiting
SMQs:, Acute pancreatitis (broad), Asthma/bronchospasm (broad), Systemic lupus erythematosus (broad), Convulsions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (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:
Current Illness: none mom knew of
Preexisting Conditions: none
Allergies: Penicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: While giving a Pfizer Covid vaccine today, a patient appeared to be fine but after a few minutes suddenly passed out and had a short 3-4 second seizure on the ground. He did hit his head and appeared to be hypoxic. We called 911 immediately and informed store management. The paramedics asked him to walk off on his own power, but they did offer to escort the family to Hospital which I believe was accepted. His mother and sister were present too.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1382051


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