Traveler Health Declaration
American Samoa

All persons entering American Samoa must complete this form before arrival.

Personal Information

First name

Please enter your name as it appears on your travel documents.

Last name

Email address

Phone number

Date of birth

Gender

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Country

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Date of arrival

Carrier

Flight/Vessel number

Country of usual residence

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Village in American Samoa or Hotel Name

Have you traveled to another country in the past 14 days?

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Have you been vaccinated for COVID-19?

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Are you experiencing any of the following symptoms?

Have you been told in the past month that you tested positive for an infectious disease?

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Other medical conditions (Optional)

Limit: 150 characters

I hereby acknowledge that I have read, understand, and agree to the terms of this application