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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1697360



Case Details

VAERS ID: 1697360 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-09-14
Onset:2021-09-14
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 202A21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Loss of consciousness, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient passed out about 10 seconds after vaccine administered, eyes remained open, his body became limp, and he remained unresponsive to verbal and physical prompts (patient''s wife rubbed patient chest to try to awaken him) for about 3 to 4 minutes. EMTs evaluated patient after he regained consciousness and found his vitals were within normal range. Patient denied suggested visit to hospital and was taken home about 45 minutes later.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1697360

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