Samoa COVID-19 Rapid Test Self-Reporting Form
Official Samoa Ministry of Health reporting portal
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Igoa Muamua
First name
Faaiu
Last name
Numera o le pepa tui. Faataitaiga - ABCD654321
Vaccination ID (Patient ID in Tamanu system). Example - ABCD654321
Aso Fanau
Date of Birth. Type your DOB or click on the icon to select using the calendar feature
MM
/
DD
/
YYYY
Ituaiga
Gender
Clear selection
Nuu / Afioaga
Village
O e a’afia i fa’amai o lo’o taua i lalo?
Do you have any underlying conditions?
Numera telefogi
Phone number
Imeli
Email address
Aso sa fa’atinoina ai le su’esu’ega
Date of Test. Type the date of the test or click on the icon to select using the calendar feature
MM
/
DD
/
YYYY
Faaiuga ole suesuega
Test result
Clear selection
Submit
Clear form
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