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From the 5/7/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 919252

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Case Details

VAERS ID: 919252 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Female  
Location: Maine  
Vaccinated:2020-12-30
Onset:2020-12-30
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest discomfort, Headache, Palpitations, Pyrexia, Rash, Skin discomfort
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 6 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: NKA
Diagnostic Lab Data: EE was seen in the emergency room and admitted to Hospital. She remains inpatient today 1/4/21.
CDC Split Type:

Write-up: Employee received COVID 19 vaccination at 9:45am on 12/30/20. ~15 min. later she developed a rash down her left arm, then down her Rt. arm. about 4 hours later she decided to go to the emergency room for Hearty Palpitations, Fever, Chest discomfort and feeling of generalized sunburn. Later developed severe headache..


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=919252


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