Personal Information Collection Statement

The personal information you provide using the Felt report form for Community Internet Intensity Maps is collected under the authority of the Resources and Technical Surveys Act and will be used by Natural Resources Canada to conduct research into earthquakes in Canada. The information may also be used to contact you for follow-up research or to confirm the data provided.

Please note that the information you provide using the Felt report form for Community Internet Intensity Maps may be routed through an American or other internationally-based server. However, in the event that this occurs, the information will be deleted from the American or internationally-based server after one week.

There are no legal or administrative consequences for refusing to provide the personal information requested. Under the Privacy Act, you have rights of access to, correction of, and protection of personal information.

The information you provide using this form is described in the following standard Personal Information Bank (PIB): Public Communications - PSU 914. For more information about this PIB and your privacy rights, please consult Info Source: Sources of Federal Government and Employee Information, which is published on the Internet by the Treasury Board of Canada Secretariat at: http://infosource.gc.ca/index-eng.asp.

How can we contact you?

For other events or historic events, go to the GSC CIIM archive. If you were in the U.S.A. at the time of the earthquake, please go to the USGS earthquake site to locate the appropriate form.

Name:

E-mail:

Phone:

Where did you feel it?

Since you are submitting this form for a new or unknown earthquake, please fill out the following information completely. This will help us accurately locate this event.

Your location when the earthquake occurred:

Street Address:

Nearest Cross Street:

City:

Province:
Select province Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories & Nunavut Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
Country:

Postal Code:

When was it?

Please fill out as completely as you can:

Date of earthquake

Month: --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day: --- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year:

Time of earthquake

Hour: --- 1 2 3 4 5 6 7 8 9 10 11 12 Minute: --- 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM / PM AM PM

Where were you?

While answering all these questions is optional, we encourage you to fill out as many as possible so we can provide a more accurate intensity estimate.

What was your situation during the earthquake?
No answer Inside Outside In stopped vehicle In moving vehicle Other
If you were inside please select the type of building or structure:
No building Single Family Home or Duplex Apartment Building Office Building/School Mobile Home with Permanent Foundation Trailer or Recr. Vehicle with No Foundation Other
If other, please describe:

Were you asleep during the earthquake?
No Slept through it Woke up
Did you feel the earthquake?

If you were asleep, did the earthquake wake you up?

Yes
No

Did others nearby feel the earthquake?
No answer/Don't know/Nobody else nearby No others felt it Some felt it, but most did not Most others felt it, but some did not Everyone or almost everyone felt it

Your experience of the earthquake:

How would you best describe the ground shaking?
No description Not felt Weak Mild Moderate Strong Violent
About how many seconds did the shaking last?

How would you best describe your reaction?
No answer/Don't remember No reaction/Not felt Very little reaction Excitement Somewhat frightened Very frightened Extremely frightened
How did you respond? (Select one.)
No answer/Don't remember Took no action Moved to doorway Ducked and covered Ran outside Other
If other, please describe:

Was it difficult to stand or walk?
No answer/Did not try No Yes

Earthquake effects:

Did you notice the swinging/swaying of doors or hanging objects?
No answer/Did not look No Yes, slight swinging Yes, violent swinging
Did you notice creaking or other noises?
No answer/Did not pay attention No Yes, slight noise Yes, loud noise
Did objects rattle, topple over, or fall off shelves?
No answer/No shelves No Rattled slightly Rattled loudly A few toppled or fell off Many fell off Nearly everything fell off
Did pictures on walls move or get knocked askew?
No answer/No pictures No Yes, but did not fall Yes, and some fell
Did any furniture or appliances slide, tip over, or become displaced?
No answer/No furniture No Yes
Was a heavy appliance (refrigerator or range) affected?
No answer/No heavy appliance No Yes, some contents fell out Yes, shifted by inches Yes, shifted by a foot or more Yes, overturned
Were free-standing walls or fences damaged?
No answer/No walls No Yes, some were cracked Yes, some partially fell Yes, some fell completely
If you were inside, was there any damage to the building? Check all that apply.

All damage types.

No damage
Hairline cracks in walls
A few large cracks in walls
Many large cracks in walls
Ceiling tiles or lighting fixtures fell
Cracks in chimney
One or several cracked windows
Many windows cracked or some broken out
Masonry fell from block or brick wall(s)
Old chimney, major damage or fell down
Modern chimney, major damage or fell down
Outside wall(s) tilted over or collapsed completely
Separation of porch, balcony, or other addition from building
Building permanently shifted over foundation

If you know the type of building (wood, brick, etc.) and/or your location (which storey, basement, penthouse, etc.) please indicate here:

Additional Comments:

You may use the next box to clarify answers or to make observations that are not accommodated by other questions. You may also use the following box to give first-person descriptions of how the earthquake affected you. GSC scientists may use some of the information that you enter in qualitative descriptions of shaking or damage in GSC publications. You would be identified as "an observer" and your location would be given in general terms. Parts of some first-person accounts may be reproduced as quotations in GSC publications.

Comment Box

To submit your completed form, press this button: