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 Info

Organization Name: *

Organization Name in Haiti:

If different from Organization Name.

Mission: *

Partners: *

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

Name: *

Title: *

Phone: *

Email: *

Address: *

If different from Primary Contact.

Name:

Title:

Phone:

Email:

Address:

Name:

Title:

Phone:

Email:

Address:

Project

Project Location: *
UrbanRural

Nearest City:

Project Type: *
CommunitySchoolHospital/ClinicOrphanageOther

Population Served: *

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.

Additional Population Information:

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

Project Information

Project Name: *

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

Founding Date:

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

History:

Water

Water/Sanitation Experience: *

YesNo

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

Experience Description: *

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.

Current Water System: *
Rain water collectionRiver/streamHand pumpElectronic pumpWellSNEP systemUnknown

Please check all that apply.

Main Water Source: *
Rain water collectionRiver/streamHand pumpElectronic pumpWellSNEP systemUnknown

Maintenance: *

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

Current Water Storage: *
CisternWater towerReservoirBucketsOtherUnknown

Please check all that apply.

Water Storage Information: *

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

Piping System Material:
PlasticMetal

Please choose an option If your water system includes piping.

Piping Size:

Please provide the measurements of the piping system in inches.

Problems: *

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.

Sharing: *
YesNo

Permissions:
I will email a report detailing the use of the donated materials to info@haitiwater.org within a month of completing the project.I will email photos to info@haitiwater.org within a month of completing the project.International Action may share information I provide through print and electronic communications, including but not limited to newsletters, email campaigns, and the International Action Website.

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

Additional Information:

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

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