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

This is VAERS ID 1768087

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Case Details

VAERS ID: 1768087 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-05-18
Onset:2021-10-05
   Days after vaccination:140
Submitted: 0000-00-00
Entered: 2021-10-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017BZ1A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, 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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: history of developmental delay, schizoaffective disorder, morbid obesity, osteoarthritis, DVT
Allergies:
Diagnostic Lab Data: COVID positive on 10/5/2021
CDC Split Type:

Write-up: COVID vaccine breakthrough case


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1768087


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