Albendazole Request Form

International Action provides albendazole pills to treat intestinal worms commonly caused by contaminated 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.

Please tell us how many albendazole pills you are requesting and how those pills will be distributed.

Please indicate whether or not your organization has experience with de-worming projects.

If yes, briefly explain your group’s experience with de-worming treatments and indicate if your staff needs training on the proper use of albendazole pills. 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 albendazole pills.

Please indicate whether your organization intends to share the albendazole pills 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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