Earthquake Risk Assessment Questionnaire

Earthquake Risk Assessment Questionnaire
Please complete this questionnaire to help assess the earthquake risk of your property or building.
Property Owner's Full Name*
First NameLast Name
Contact Email Address*
example@example.com
Property Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Year of Construction*
Single-family houseApartment buildingCommercial buildingOther
Number of Floors*
Structural Assessment*
Rows Condition Retrofitted for Earthquake
Foundation
Walls
Roof
Distance to Nearest Known Fault Line (km)*
YesNoUnknown
Emergency kit availableEvacuation plan in placeStructural retrofitting doneSecured heavy furniture/appliancesNone of the aboveOther
How would you rate your building's overall earthquake safety?*
Additional Comments or Concerns
Should be Empty: