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.
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:
Nearest Cross Street:
Northwest Territories & Nunavut
Prince Edward Island
When was it?
Please fill out as completely as you can:
Date of earthquake
Time of earthquake
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?
In stopped vehicle
In moving vehicle
If you were inside please select the type of building or structure:
Single Family Home or Duplex
Mobile Home with Permanent Foundation
Trailer or Recr. Vehicle with No Foundation
If other, please describe:
Were you asleep during the earthquake?
Slept through it
Did you feel the earthquake?
If you were asleep, did the earthquake wake you up?
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?
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
How did you respond? (Select one.)
No answer/Don't remember
Took no action
Moved to doorway
Ducked and covered
If other, please describe:
Was it difficult to stand or walk?
No answer/Did not try
Did you notice the swinging/swaying of doors or hanging objects?
No answer/Did not look
Yes, slight swinging
Yes, violent swinging
Did you notice creaking or other noises?
No answer/Did not pay attention
Yes, slight noise
Yes, loud noise
Did objects rattle, topple over, or fall off shelves?
No answer/No shelves
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
Yes, but did not fall
Yes, and some fell
Did any furniture or appliances slide, tip over, or become displaced?
No answer/No furniture
Was a heavy appliance (refrigerator or range) affected?
No answer/No heavy appliance
Yes, some contents fell out
Yes, shifted by inches
Yes, shifted by a foot or more
Were free-standing walls or fences damaged?
No answer/No walls
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.
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:
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.
To submit your completed form, press this button: