Filter Installation Worksheet
Date: _______/_______/________ Money paid : ___________________
1. Community: _________________________________________________________
2. Household number (if available):_______________ Zip Tie Number:___________
3. Name of facilitator present during installation:
____________________________________________________________________
4. Name of the household member present during installation:
____________________________________________________________________
5. Who is the person responsible for caring for the filter?
____________________________________________________________________
Observation:
6. Did the user receive the following?
a. Brochure Yes No
b. Explanation of how to use Yes No
c. Lid Yes No
b. Diffuser Plate Yes No
7. Where was the filter installed in the home?
8. Flow rate measure: ______________________ml per minute
9. Please note the age and sex of people who live in the household:
Sex: >=5 years old <5 years old Total
Male
Female
Other observations:
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