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From the 12/31/2003 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 80969

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Case Details

VAERS ID: 80969 (history)  
Form: Version .0  
Age: 76.0  
Sex: Male  
Location: Unknown  
Vaccinated:1995-12-13
Onset:1995-12-23
   Days after vaccination:10
Submitted: 1996-01-11
   Days after onset:19
Entered: 1996-01-24
   Days after submission:13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HAVRIX / SMITHKLINE - / 0 - / -

Administered by: Other       Purchased by: Unknown
Symptoms: ATAXIA
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: pt also recvd cholera & typhoid vax
Current Illness:
Preexisting Conditions: epilepsy
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recvd vax 13DEC95 & 10 days p/vax pt exp broad based ataxia & was hospitalized x 2 days;pt is currently being evaluated by neurologist & is receiving physical therapy;No further details are available @ this time;


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