State/UT Country Zip/Post/Pincode
Earthquake felt
On Year Month Day Hour Minutes
1.What was your situation during earthquake?(select one) If Other Pl. mention here
2.If you were inside please select the type of building or structure(select one) If Other Pl. describe here
3.Were you asleep during the earthquake? No Slept through it Woke me up
4.Did you feel the earthquake? (If you were asleep, did the earthquake wakeup you?) NO YES
Did others nearby feel the earthquake?(select one)
Your experience of the earthquake
5.How would you best describe the ground shaking?(Select one)
6.About how many seconds did the shaking last?
7.How would you best describe your reaction?(Select one)
8.How did you response?(Select one) If Other please describe here
9. Was it difficult to stand or walk? NO YES
Earthquake effects
10.Did you notice the swinging/swaying of doors or hanging objects? No Yes Slight Swinging Yes Violent Swinging
11.Did you notice creaking or other noises? No Yes Slight Noise Yes Loud Noise
12.Did Objects topple over or fall off shelves?(select one)
13.Did pictures on walls move or get knocked askew? No Yes, but did not fall Yes, and some fell
14.Did any furniture or appliances slide, tip over, or become displaced? NO YES
15.Was a heavy appliance [refrigerator or Almirah] affected?(select one)
16.Were free-standing walls or fences damaged?(select one)
17.If you were inside, was there any damage to building? Check all that apply.
No damage
Hairline cracks in walls
One or several cracked windows
A few large cracks in walls
Many large cracks in walls
Ceiling tiles or lighting fixtures fell
Cracks in Chimney
Many windows cracked or broken out
Masonry fell from block or brick walls
Old chimney, major damage or fell down
Modern chimney, major damage or fell down
Outside wall[s] tilted over or collapsed
Separation of porch, balcony, or other Addition from building
Building moved over foundation
If you know the type of building [wood, brick. etc.] and/or your location [basement, penthouse, etc.] please indicate here
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