Chlorine Request Form

International Action has enough granular chlorine to provide every Haitian with safe, treated water for six to nine months. Additionally, International Action provides training on how to use chlorine and test chlorine levels in water. Please complete this form, and we'll do our best to meet the needs of your project.

Organization Information

If different from Organization Name.

Please list any partners your organization has worked with in the past or currently works with to provide services or materials to Haiti.

Contact Information
Primary Contact
Project

If your project location is rural, please list the nearest city/urban center.

Please describe the population (for example: number of residents in the communtiy, students attending the school, patients visiting the clinic per day/month/year, children living in the orphanage, etc.) served by your project.

Please provide any other relevant information about the population served by your project.

Project Information

Please provide the name of the community, school, hospital/clinic, orphanage, or other project.

Please provide the date the community, school, hospital/clinic, orphanage, or other project was founded.

You may provide a brief history of the community, school, hospital/clinic, orphanage, or other project, if you wish.

Water

Please indicate whether or not your organization has experience with water or sanitation projects.

If yes, briefly explain your group’s experience with water projects and indicate if your staff needs training on the proper use of granular chlorine. If no, briefly list projects completed by the organization (no more than three) and who will be receiving training from International Action staff on proper use of granular chlorine.

Please check all that apply.

Please provide the name of the person responsible for the maintenance of your main water source/system.

Please check all that apply.

Please describe your water storage system, to include: size/capacity and materials (plastic, cement, etc.). If "Other" was selected above, please explain.

Please choose an option If your water system includes piping.

Please provide the measurements of the piping system in inches.

Please describe any water-related problems or problems you've noticed due to contamination that are currently impacting the community, school, hospital/clinic, orphanage, or other project.

Please indicate whether your organization intends to share the chlorine solution or clean water with neighboring communities, organizations, schools, hospitals, etc.

Please check beside the statements to indicate that you agree to the request.

Please provide any additional information you would like us to have when considering your project.

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