Are you the applicant?
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Yes
No
Application Number:
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1 2 3 4 5 6 7 8 9 10
First Name:
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Middle Name (or initial):
Last name:
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Address:
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Village:
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A'asu Afao Afono Agugulu Alao Alega Alofau Amaluia Amanave Amaua Amouli Anua Aoa Aoloau Asili Atu'u Aua Auasi Auma Aumi Aunu'u Auto Avalo Faga'alu Faga'itua Fagali'i Fagamalo Faganeanea Fagasa Fagatogo Failolo Falesao Faleniu Fatumafuti Futiga Ili'ili Lauli'i Leloaloa Leone Leusoali'i Luma Mala Malaeimi Malaeloa Maloata Mapusagafou Masausi Masefau Matu'u Mesepa Nua Nu'uuli Ofu Olosega Onenoa Pagai (Eastern District - Sa'ole County) Pagai (Eastern District - Sua County) Pago Pago Pava'ia'i Poloa Puapua Sa'ilele Satala Se'etaga Sili Si'ufaga Swains Tafuna Taputimu Tula Utulei Utumea East Utumea West Utusia Vailoatai Vaitogi Vatia
Cell phone number:
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Home phone number:
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Birthdate:
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Today M-D-Y
Current Age at Time of Application:
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Place of Birth:
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American Samoa (US Territory) Samoa Fiji Tonga Philippines Taiwan China Japan Korea United States of America Australia New Zealand Other
Email:
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Secondary Contact Person Information: In the event that we cannot contact you, please provide the following information of someone who we can reach out to on your behalf.
First Name:
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Relation:
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Phone:
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**Please check the appropriate boxes
Gender:
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Male
Female
Religion:
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Anglican Assembly of God (AOG) Baptist Bahá'í Buddhist Catholic / Roman Catholic Church of the Nazarene Congregational Christian Church of Samoa (CCCAS) The Church of Jesus Christ (CCJS) Full Gospel Hindu Jehovah's Witnesses (JW) Judaism The Church of Jesus Christ of Latter-day Saints (LDS) London Missionary Society (LMS) Methodist Muslim Non-denominational No religious affiliation (N/A) Pentecostal Seventh-day Adventist (SDA) United Pentecostal Church (UPC) Other
Other (please specify):
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Marital Status:
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Single
Widowed
Married
Divorced
Separated
Single
Widowed
Married
Divorced
Separated
Race:
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Samoan Tongan Fijian Filipino Korean Japanese Chinese Taiwanese Aboriginal Australian Torres Strait Islander Māori Black/Afro-descendant White/Caucasian Other
Other (please specify):
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Employment:
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Employed
Self Employed
Unemployed
Retired
Student
Employed
Self Employed
Unemployed
Retired
Student
If yes, who is your employer?
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Has the applicant ever been in the military?
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Yes
No
What type of cancer do you have?
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Abdominal Ampullary (pancreas) Angiosarcoma Bladder Bone Brain Breast Cervical Colon Endometrial Esophogus eye Gallbladder Gastric Intestinal Kidney Leukemia Liver Lung Myeloma Myxoid Liposarcoma Nasophasyengol Osteosarcoma Ovarian Pancreatic Prostate Rectal Renal Salivary Skin Stem Cell Stomach Thymus Thyroid Uterine Laryngeal Langerhaus Cell Histiocytosis Lymphoma Papillary Vaginal Mouth (mucoepidermoid carcinoma) Retinoblastoma Oral Squamous Cell Carcinoma Basal Cell Carcinoma Rhabdomyosarcoma Peritoneal (lining of abdomen) Squamous Cell Carcinoma Throat (incl soft palate carcinoma) Acute Lymphoblastic Leukemia (ALL) Acute Myeloid Leukemia (AML) Chronic Lymphocytic Leukemia (CLL) Chronic Myelogenous Leukemia (CML) Multiple Other
Yes
No
Cancer Description (optional):
What age were you diagnosed?
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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
What year were you diagnosed?
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1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
If you are uncertain, please provide the approximate year
Where were you diagnosed?
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Will you have OR have you had any of the following done? (Please check all that apply)
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Oncology
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Yes
No
Surgery
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Yes
No
Chemotherapy
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Yes
No
Palliative Care
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Yes
No
Palliative Care - Country
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Off-Island Referral
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Yes
No
Off-island Referral - Country
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Off-island Referral - State
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Off-island Referral - City
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Radiation Therapy
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Yes
No
Radiation Therapy - Country
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Radiation Therapy - State
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Immunotherapy
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Yes
No
Targeted Therapy
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Yes
No
Targeted Therapy - Country
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Hormone Therapy
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Yes
No
Hormone Therapy - Country
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Stem Cell Transplant
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Yes
No
Stem Cell Transplant - Country
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Stem Cell Transplant - State
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Stem Cell Transplant - City
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Is this your first time applying for the ASCCC Tautai Laveai Program?
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Yes
No
If no, when was the last time that you applied for the ASCCC Tautai Laveai Program?
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How were you referred to the ASCCC Program:
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ASC Cancer Coalition Employee/Member
Family Member
Friend
DOH
LBJ/ Doctor
Radio
Social Media
Newspaper
ASCCC Event
Health (DOH/LBJ/Dr - Unspecified)
ASC Cancer Coalition Employee/Member
Family Member
Friend
DOH
LBJ/ Doctor
Radio
Social Media
Newspaper
ASCCC Event
Health (DOH/LBJ/Dr - Unspecified)
Insurance type?
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Medicare/Medicaid
N/A
Other
Private
VA/TRICARE
Medicare/Medicaid
N/A
Other
Private
VA/TRICARE
Date of Application Submission:
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Today M-D-Y
Application Year:
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Application Method:
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Intake Form (Data Entry)
Online (Data Entry)
Online (RC Survey)
Intake Form (Data Entry)
Online (Data Entry)
Online (RC Survey)
IMPORTANT PATIENT/APPLICANT AUTHORIZATION AND ACKNOWLEDGEMENT:
I authorize the release of any medical or other information necessary to process this application to the ASCCC (American Samoa Community Cancer Coalition). The information that ASCCC obtains will be used to determine the eligibility of the applicant. I understand that the information may also be used to provide statistical data information for the ASCCC and will become the property of the organization. The ASCCC may publicly use my name a photo to inform donors about my stipend award should my application be approved. I also understand that by typing in my name electronically, it is as valid as an actual authorized signature. I understand that the ASCCC cannot provide a stipend to a patient/Applicant's family if this person has passed away before receiving the stipend. I understand that stipends are provided in the form of a bank check made payable to the Patient/Applicant or parent of a minor Patient/Applicant. This also certifies that the foregoing information is true, accurate and complete.
Print Patient's/Applicant's Name:
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Patient's/Applicant's Signature
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Patient's/Applicant's Signature**By typing in my name electronically, it is as valid as an actual authorized signature *NOTE: If data is being entered from physical signed application form, please type the full name of the applicant to acknowledge signature, before uploading a copy of their application below.
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Authorized Party Name:
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Authorized Party Signature:
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Date of signature:
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Today M-D-Y
Please upload physical application form here (ONLY if performing manual data entry of any physical application submitted BEFORE February 2026).
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Please attach ONE off the following documents confirming cancer diagnosis:
1. Doctor's signed letter on hospital letterhead stating a confirmed diagnosis
OR
2. Medical record reflecting diagnosis (must have patient's name and Medical Record Number (MRN) or other identifying data).
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