SUNY Potsdam Research Earthquake Intensity Questionnaire


November 11, 2002
NOTICE: Form is not entirely online - mail from here goes to eric (at) thern.org

This may or may not still work, so don't put too much effort into it -- just said in advance to ease frustration!

- Eric Thern

INTENSITY QUESTIONNAIRE

1) Did you notice an earthquake recently?
Your response to this questionnaire is important even if you chose "no".
If YES please give time and date: TIME: DATE:
Your location at the time: STATE: TOWN OR CITY:
STREET ADDRESS:
NEAREST CROSS STREET
EMAIL ADDRESS
2) Were You:
3) If indoors, on what floor were you on?
4) Were You:
5) The building shook:
6) Hanging objects swung:
7) Did you hear the earthquake?
If yes, indicate direction from which noise came:
8) Did you notice any of the following? windows and dishes rattle
walls creak
parked cars move
small objects shift
trees and shrubbery shake
objects overturned
objects fall from shelves
large objects and furniture shift
plaster and glass crack
dishes break
chimney bricks displaced
liquids set into strong motion
twisted or broken chimneys
plaster fallen
brickwork, tiles, etc. fallen from structures
windows broken
9) Indicate effects of the following types to interior walls if any: Plaster:
Dry Wall:
Ceiling Tiles:
10) Did you also notice any of the following? furniture broken
tombstones displaced
tombstones rotated or fallen
elevated water tanks cracked
elevated water tanks fallen
evelated water tanks twisted
waves on lakes, ponds, pools
11) Did you notice ground cracks on: wet ground
steep slopes
dry and level ground
12) Did you have any difficulty standing?:
13) Please add any additional comments or descriptions here:






INTENSITY QUESTIONNAIRE -- Original form from Dr. Frank Revetta - SUNY Potsdam
Translated into an online form by Eric Thern