HaitiOne Humanitarian Assessment Form 
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Organization/School/Church Name 
(Non Òganizasyon/Lekò/Legliz)
 *
Point of Contact (Name)
(Pwen kontak la)
 *
Point of Contact (Email)
(Adrès imel pwen kontak la)
 *
Point of Contact (Phone number)
(Telephone Pwen kontak la)
GPS Coordinates or Address of Organization's Location
Example Format (18.647000, -74.114583)

(Kowòdone gps kote òganizasyon an ye 

Egzanp (8.647000, -74.114583))

Department
(Depatman)
 *
Community/Neighborhood (s) That You Serve 
(Kominote/zòn wap sèvi)
 *
Description of humanitarian need you see in the communities you serve (e.g. food, water, shelter, medical). 

*Please give as many details as possible ( how many people are in need of what specific aid or intervention, estimated quantity of needed supplies etc., needed services).

(Dekri between imanitè ou wè nan kominote wap sèvi yo. (Tankou manje, dlo, kay, medikal)
Tanpri bay bon detay (konbyen moun ki nan bezwen epi ki bezwen espesifik, estime kantite bezwen yo oubyen sèvis yo bezwen))
 *
Please Check all of the Community Needs that Apply
(Tanpri, check tout between kominotè ki koresponn)
 *
Required
Please Describe the Current State of Food Security in the Area You Serve
(Number of people impacted by food/resource shortage)
(Tanpri dekri sitiyasyon sekirite alimantè aktyèl la nan zone w’ap sèvi a.(Kantite moun ratman manje enpakte))
 *
Please Describe the Current Status/Operations of Schools in the Areas you Serve

(Tanpri, dekri kòman lekòl nan zone ou yo ap fonksyone aktyèlman)

Is there Active Governmental Assistance Present?
(Eske gen asistans gouvènmantal aktif?)
Clear selection
Are there Other NonGovernmental Organizations Actively Providing Aid?
(Eske gen NGO aktif?)
Clear selection
Is Your Organization Ready and Capable to Distribute or Food, Medical Supplies etc?
(Eske Òganizasyon w la prè epi kapab distribiye manje, materyèl medikal etc?)
 *
To join our HaitiOne Whatsapp group, kindly provide your phone number if you're not already a member.
(Pou w ka fè pati group whatsapp Haitione lan, ekri numero telephone ou is ou pat ko yon manm gwoup la.)
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