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

This is VAERS ID 1696249

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Case Details

VAERS ID: 1696249 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-04-12
Onset:2021-09-12
   Days after vaccination:153
Submitted: 0000-00-00
Entered: 2021-09-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 207A21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: COVID-19, Dyspnoea, Pyrexia, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: no known allergies
Diagnostic Lab Data: COVID PCR + 9/13/21
CDC Split Type:

Write-up: fever, SOB


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