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

This is VAERS ID 1695814

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Case Details

VAERS ID: 1695814 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-05-07
Onset:2021-09-11
   Days after vaccination:127
Submitted: 0000-00-00
Entered: 2021-09-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 RA / SYR

Administered by: Private       Purchased by: ?
Symptoms: Blood test, Deep vein thrombosis, Ultrasound Doppler abnormal
SMQs:, Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad), Cardiomyopathy (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Blood test Ultrasound 9-12-2021
CDC Split Type:

Write-up: Deep Vein Thrombus. Mid femoral vein to calf.


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