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Felt report form for Community Internet Intensity Maps

DID YOU FEEL IT? REPORT IT HERE!

You can help provide information about the extent of shaking and damage for earthquakes in Canada. The specific details you may provide will help us determine how your area may respond to future earthquakes.

While identifiers such as name, e-mail address, and telephone are optional, please provide as complete address information as possible to help us locate the intensity in your area.

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:

Country:

Postal Code:

When was it?

Please fill out as completely as you can:

Date of earthquake

Month: Day: Year:

Time of earthquake

Hour: Minute: 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?

If you were inside please select the type of building or structure:

If other, please describe:

Were you asleep during the earthquake?

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

Yes or no Yes
No

Did others nearby feel the earthquake?

Your experience of the earthquake:

How would you best describe the ground shaking?

About how many seconds did the shaking last?

How would you best describe your reaction?

How did you respond? (Select one.)

If other, please describe:

Was it difficult to stand or walk?

Earthquake effects:

Did you notice the swinging/swaying of doors or hanging objects?

Did you notice creaking or other noises?

Did objects rattle, topple over, or fall off shelves?

Did pictures on walls move or get knocked askew?

Did any furniture or appliances slide, tip over, or become displaced?

Was a heavy appliance (refrigerator or range) affected?

Were free-standing walls or fences damaged?

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:

General Disclaimer.

Personal Information Collection Statement

The personal information you provide on this form 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. 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 on 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.