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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 81040

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Case Details

VAERS ID: 81040 (history)  
Form: Version .0  
Age: 56.0  
Sex: Female  
Location: Unknown  
Vaccinated:1995-08-31
Onset:1995-08-31
   Days after vaccination:0
Submitted: 1995-09-13
   Days after onset:13
Entered: 1996-01-24
   Days after submission:133
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HEPA: HAVRIX / SMITHKLINE - / 0 RA / IM

Administered by: Other       Purchased by: Unknown
Symptoms: PRURITUS, RASH, URTICARIA
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? No
Previous Vaccinations:
Other Medications: premarin, provera
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: pt recvd vax;w/in few hrs exp itching, red welts all over & rash on trunk; to er; tx w/ dph;


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