Did you feel it – Tell us !!

Your location when the earthquake occurred (use map to indicate location)

1. Did you feel the earthquake?
NoYes

2. At the time of earthquake, were you
Inside the buildingOutside the buildingIn an open area of landIn a moving vehicleNear the coastBy the river

3. Describe the earthquake shaking. Is it?
WeakModerateStrongSevere

4. Your reaction to the shaking
No reactionExcitedFrightenVery frighten

5. Your response to the shaking
No responseRan outsideRan in to the houseDrop and cover

6. Was it difficult to stand or walk?
NoYesDon't know

7. Did objects swing?
NoYes, slight swingingYes, violent swingingCould not verify

8. Did you hear rattling of doors, windows, kitchen utensils, etc?
NoYes, slight noiseYes, loud noiseCould not verify

9. Did objects shifted and fell over or fell from shelves?
NoYes, only light objects shifted and fell overYes, heavy objects shifted and fell overCould not verify

10. Building damage
NoYes, slight damageYes, considerable damage

11. Type of building
Bush materialSemi-permanentPermanentBrick

12. Type of building damage
Hairline cracks in wallsFew large cracks in wallsMany large cracks in wallsCeiling tiles or light fixtures fellOne or several windows are crackedMany windows are crackedMany windows are crackedRoofs and walls fell

13. Was there any damage to water tanks?
NoYes, water sloshed from one or severalYes, damage was minorYes, damage was considerable

14. Where there any landslides nearby?
NoYes, from road cuttingsYes, from slopes and mountain areas

15. Did the earthquake generate a tsunami?
NoYes, from road cuttingsYes, a mild tsunamiYes, significant tsunami

Additional comments if any: