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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1694306

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Case Details

VAERS ID: 1694306 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-09-08
Onset:2021-09-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 201A21A / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cold sweat, Computerised tomogram, Dizziness, Fall, Head injury, Hyperhidrosis, Pallor, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: NA
Current Illness: NA
Preexisting Conditions: DJD
Allergies: NKDA
Diagnostic Lab Data: Patient declined squad ride to local hospital, but did go by private car and was driven by a friend on 9/8/2021. Patient went to ED and was discharged after CT cleared him with no concerning injuries from fall.
CDC Split Type:

Write-up: Patient received J & J vaccine in the clinic and approximately 3 mins after administration of vaccine, patient fell to the floor from a sitting position and was unresponsive. Smelling salt was used, patient then became alert but stated "Im dizzy". Patient was clammy, pale and diaphoretic. VS obtained at 1459 BP-122/92, HR-56, SPO2-RA 98%, Left patient on the floor for approximately 20 mins until he was in no acute distress. VS obtained at 1505 BP 130/92, HR-64, SP02- RA 99%, VS obtained AT 1515 BP-136/92, HR-56. When patient fell to the floor he was twisted to the left of his body. Bump noted to left temple region approximately 15mins after fall. Face mask was on patient and staff.


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