We apprieciate the contribution of supplies from The Ministere de la Sante and the Pan American Health Organization. Our organization has a visiting medical team that requests supplies to have an immunization clinic. Thank you.

Date:__________________

Name/Nom Trip Leader/Responsible:____________________________________________________ Title:___________ Last/Surnom                            First/Prenom            Organization:_____________________________________________________________________________ Street Address:___________________________________________________________________________ City/Ville:____________________State/Department_____________________Country:__________________ Arrival Date:_________________________________ Departure Date:______________________________ Location of Clinic:____________________________ Commune:___________________________________ Name/Information on Clinic:________________________________________________________________ Visiting Team Contact #1:__________________________________________________________________

Telephone:___________________ Email:____________________________

Visiting Team Contact #2:__________________________________________________________________

Telephone:___________________ Email:____________________________

Contact #1 in Haiti:________________________________________________________________________

Telephone:___________________ Email:____________________________

Contact #2 in Haiti:________________________________________________________________________

Telephone:___________________ Email:____________________________

Immunization Project Estimates of Patients: Estimate # children                                 Ages 0-1 Year: ________ Ages 1-4: ________ Ages 4-14: ________   Estimate # Women of Child-Bearing Age 15-45 (For Vaccination with Tetanus/diptheria): ______ Formula for Medical Clinic: If 65% of visits are women; 90% of child-bearing age= 54% need dT Adult Vaccine Each mother brings 1-2 children, ~50% with full immunization (ask mother or see vaccine card) X = Total Visits      X x 0.54 = # doses Adult dT      (X x 0.54) x 0.75 = Number DTP, Measles, Polio Or estimate 55% of patients need adult dT and 40% need childhood immunizations If clinic is publicized as an Immunization Clinic, estimate 75% of women and 90% of children will need immunizations. Verify all information. This form is a service of The Haiti Connection, which is not responsible for the information or a clinic.