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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1693534

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Case Details

VAERS ID: 1693534 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-09-11
Onset:2021-09-11
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 08802IA / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Rash, Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: fish oil, vit D, flax seed, lisinopril, digoxin, Claritin.
Current Illness: n/a
Preexisting Conditions: none
Allergies: Aloe, petroleum, latex, silicone, hay fever, dust, mold.
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Generalized body rash with hives, approx. 2 hours after injection.


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