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<!DOCTYPE html>
<html>
<head>
<link href="https://ssl.gstatic.com/docs/spreadsheets/forms/favicon_jfk2.png"
rel="shortcut icon" type="image/x-icon"/>
<meta http-equiv="Content-type" content="text/html; charset=utf-8"/>
<meta http-equiv="X-UA-Compatible" content="IE=10; chrome=1;"/>
<meta name="viewport" content="width=device-width"/>
<meta name="fragment" content="!"/>
<base target="_blank"/>
<title>Rapid Building Assessment</title>
<link href='https://docs.google.com/static/forms/client/css/3227177689-formview_ltr.css'
type='text/css' rel='stylesheet'/>
<link href="https://netdna.bootstrapcdn.com/twitter-bootstrap/2.3.1/css/bootstrap-combined.min.css"
rel="stylesheet">
<script src="https://netdna.bootstrapcdn.com/twitter-bootstrap/2.3.1/js/bootstrap.min.js"></script>
</head>
<body dir="ltr" class="ss-base-body">
<div itemscope itemtype="http://schema.org/CreativeWork/FormObject">
<meta itemprop="name" content="Rapid Building Assessment">
<meta itemprop="description" content="Checklist for the post-disaster safety evaluation of buildings.">
<meta itemprop="url" content="https://docs.google.com/forms/d/1hkxm4XCm8Vey0dsu2GjB1iMgZVzWVTRbZXSZ1EyNY8A/viewform">
<meta itemprop="embedUrl"
content="https://docs.google.com/forms/d/1hkxm4XCm8Vey0dsu2GjB1iMgZVzWVTRbZXSZ1EyNY8A/viewform?embedded=true">
<meta itemprop="faviconUrl" content="https://ssl.gstatic.com/docs/spreadsheets/forms/favicon_jfk2.png">
<a class="ss-edit-link" href="https://docs.google.com/forms/d/1hkxm4XCm8Vey0dsu2GjB1iMgZVzWVTRbZXSZ1EyNY8A/edit">Edit
this form</a>
<div class="ss-form-container">
<div class="ss-top-of-page">
<div class="ss-form-heading"><h1 class="ss-form-title" dir="ltr">Rapid Building Assessment</h1>
<p></p>
<div class="ss-form-desc ss-no-ignore-whitespace">Checklist for the post-disaster safety evaluation of
buildings.
</div>
<hr class="ss-email-break" style="display:none;">
<div class="ss-required-asterisk">*Required</div>
</div>
</div>
<div class="ss-form">
<form action="https://docs.google.com/forms/d/1hkxm4XCm8Vey0dsu2GjB1iMgZVzWVTRbZXSZ1EyNY8A/formResponse"
method="POST" id="ss-form" target="_self" onsubmit="" class="form-horizontal">
<fieldset>
<div class="control-group">
<label class="control-label" for="entry_673765125">
<strong>Territorial Authority</strong>
</label>
<div class="controls">
<input type="text" name="entry.673765125" id="entry_673765125" placeholder="" class="input-xlarge"/>
<span class="help-block">The region in which the disaster has occurred.</span>
</div>
</div>
</fieldset>
<fieldset>
<legend>Location Details</legend>
<div class="control-group errorbox-good">
<label class="control-label" for="entry_1287643208">
<strong>Date & Time</strong>
<span class="ss-required-asterisk">*</span>
</label>
<div class="controls form-inline">
<input type="text" name="entry.1287643208" id="entry_1287643208" placeholder="2013-01-01"
class="input-small"/>
<input type="text" name="entry.873204302" id="entry_873204302" placeholder="00:00" class="input-small"/>
<span class="help-block"></span>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_1346211172">
<strong>Inspector's Name</strong>
<span class="ss-required-asterisk">*</span>
</label>
<div class="controls">
<input type="text" name="entry.1346211172" id="entry_1346211172" placeholder="" class="input-xlarge"/>
<span class="help-block"></span>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_2058505702">
<strong>Building Name</strong>
</label>
<div class="controls">
<input type="text" name="entry.2058505702" id="entry_2058505702" placeholder="" class="input-xlarge"/>
<span class="help-block"></span>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_966638966">
<strong>Building Address</strong>
<span class="ss-required-asterisk">*</span>
</label>
<div class="controls">
<textarea rows="4" name="entry.966638966" id="entry_966638966" placeholder="Text input"
class="input-xlarge"></textarea>
<span class="help-block"></span>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_417074850">
<strong>Owner/Occupier Details</strong>
</label>
<div class="controls">
<textarea rows="4" name="entry.417074850" id="entry_417074850" placeholder="Text input"
class="input-xlarge"></textarea>
<span class="help-block"></span>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_105052433">
<strong>Owner/Occupier Phone Contact Number</strong>
</label>
<div class="controls">
<input type="text" name="entry.105052433" id="entry_105052433" placeholder="" class="input-xlarge"/>
<span class="help-block"></span>
</div>
</div>
</fieldset>
<fieldset>
<legend>TAG Decision</legend>
<div class="control-group">
<label class="control-label" for="entry_1869247576">
<strong>Building Status</strong>
<span class="ss-required-asterisk">*</span>
</label>
<div class="controls">
<label class="radio">
<input type="radio" name="entry.480684441" id="group_480684441_1" value="Inspected (Green)">
Inspected (Green)
</label>
<label class="radio">
<input type="radio" name="entry.480684441" id="group_480684441_2" value="Restricted (Yellow)">
Restricted (Yellow)
</label>
<label class="radio">
<input type="radio" name="entry.480684441" id="group_480684441_3" value="Unsafe (Red)">
Unsafe (Red)
</label>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_1893116018">
<strong>Record any written restrictions exactly as noted on the TAG</strong>
</label>
<div class="controls">
<textarea rows="4" name="entry.1893116018" id="entry_1893116018" placeholder="Text input"
class="input-xlarge"></textarea>
<span class="help-block"></span>
</div>
</div>
</fieldset>
<fieldset>
<legend>Building Details</legend>
<div class="control-group">
<label class="control-label" for="entry_492150768">
<strong>Type of Construction</strong>
<span class="ss-required-asterisk">*</span>
</label>
<div class="controls">
<label class="radio">
<input type="radio" name="entry.30911769" id="group_30911769_1" value="Timber frame">
Timber Frame
</label>
<label class="radio">
<input type="radio" name="entry.30911769" id="group_30911769_2" value="Steel frame">
Steel Frame
</label>
<label class="radio">
<input type="radio" name="entry.30911769" id="group_30911769_3" value="Concrete frame">
Concrete Frame
</label>
<label class="radio">
<input type="radio" name="entry.30911769" id="group_30911769_4" value="Tilt-up concrete">
Tilt-up Concrete
</label>
<label class="radio">
<input type="radio" name="entry.30911769" id="group_30911769_5" value="Concrete shear wall">
Concrete Shear Wall
</label>
<label class="radio">
<input type="radio" name="entry.30911769" id="group_30911769_6" value="Unreinforced masonry">
Unreinforced Masonry
</label>
<label class="radio">
<input type="radio" name="entry.30911769" id="group_30911769_7" value="Reinforced masonry">
Reinforced Masonry
</label>
<label class="radio">
<input type="radio" name="entry.30911769" id="group_30911769_8" value="__other_option__">
Other
</label>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_492150768">
<strong>Primary Occupancy</strong>
<span class="ss-required-asterisk">*</span>
</label>
<div class="controls">
<label class="radio">
<input type="radio" name="entry.1387475536" id="group_1387475536_1" value="Dwelling">
Dwelling
</label>
<label class="radio">
<input type="radio" name="entry.1387475536" id="group_1387475536_2" value="Other Residential">
Other Residential
</label>
<label class="radio">
<input type="radio" name="entry.1387475536" id="group_1387475536_3" value="Public Assembly">
Public Assembly
</label>
<label class="radio">
<input type="radio" name="entry.1387475536" id="group_1387475536_4" value="School">
School
</label>
<label class="radio">
<input type="radio" name="entry.1387475536" id="group_1387475536_5" value="Commercial / Offices">
Commercial / Offices
</label>
<label class="radio">
<input type="radio" name="entry.1387475536" id="group_1387475536_6" value="Industrial">
Industrial
</label>
<label class="radio">
<input type="radio" name="entry.1387475536" id="group_1387475536_7" value="Government">
Government
</label>
<label class="radio">
<input type="radio" name="entry.1387475536" id="group_1387475536_8" value="__other_option__">
Other
</label>
</div>
</div>
<div class="control-group">
<label class="control-label" for="">
<strong>Heritage Listed</strong>
</label>
<div class="controls">
<input type="checkbox" name="entry.249552978" id="group_249552978_1" value="Heritage Listed"/>
</div>
</div>
</fieldset>
<fieldset>
<legend>Building Condition</legend>
<div class="alert alert-info">Make sure to investigate site hazards such as gas, electricity,
sanitary sewer, stormwater or hazardous materials/processes</div>
<table class="table table-striped">
<thead>
<tr>
<th>Observed Conditions</th>
<th>None/Minor</th>
<th>Moderate</th>
<th>Severe</th>
</tr>
</thead>
<tbody>
<tr>
<td>Collapse, partial collapse, off foundation</td>
<td><input type="radio" name="entry.1229463162" id="group_1229463162_1" value="None / Minor"/></td>
<td><input type="radio" name="entry.1229463162" id="group_1229463162_2" value="Moderate"/></td>
<td><input type="radio" name="entry.1229463162" id="group_1229463162_3" value="Severe"/></td>
</tr>
<tr>
<td>Building or storey leaning</td>
<td><input type="radio" name="entry.490084231" id="group_490084231_1" value="None / Minor"</td>
<td><input type="radio" name="entry.490084231" id="group_490084231_2" value="Moderate"></td>
<td><input type="radio" name="entry.490084231" id="group_490084231_3" value="Severe"></td>
</tr>
<tr>
<td>Racking damage to walls, other structural damage</td>
<td><input type="radio" name="entry.1036021280" id="group_1036021280_1" value="None / Minor"></td>
<td><input type="radio" name="entry.1036021280" id="group_1036021280_2" value="Moderate"></td>
<td><input type="radio" name="entry.1036021280" id="group_1036021280_3" value="Severe"></td>
</tr>
<tr>
<td>Chimney, parapet or other falling hazard</td>
<td><input type="radio" name="entry.1033370332" id="group_1033370332_1" value="None / Minor"></td>
<td><input type="radio" name="entry.1033370332" id="group_1033370332_2" value="Moderate"></td>
<td><input type="radio" name="entry.1033370332" id="group_1033370332_3" value="Severe"></td>
</tr>
<tr>
<td>Ground slope movement or cracking</td>
<td><input type="radio" name="entry.1127421031" id="group_1127421031_1" value="None / Minor"></td>
<td><input type="radio" name="entry.1127421031" id="group_1127421031_2" value="Moderate"></td>
<td><input type="radio" name="entry.1127421031" id="group_1127421031_3" value="Severe"></td>
</tr>
<tr>
<td>Other*</td>
<td><input type="radio" name="entry.53532088" id="group_53532088_1" value="None / Minor"></td>
<td><input type="radio" name="entry.53532088" id="group_53532088_2" value="Moderate"></td>
<td><input type="radio" name="entry.53532088" id="group_53532088_3" value="Severe"></td>
</tr>
</tbody>
</table>
<div class="control-group">
<label class="control-label" for="entry_1867868417">
<strong>* Specify other hazards</strong>
</label>
<div class="controls">
<textarea rows="5" name="entry.1867868417" id="entry_1867868417" placeholder="Text input"
class="input-xlarge"></textarea>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_10433717">
<strong>Estimated Building Damage</strong>
<span class="ss-required-asterisk">*</span>
</label>
<div class="controls">
<label class="radio">
<input type="radio" name="entry.1346467970" id="group_1346467970_1" value="None">
None
</label>
<label class="radio">
<input type="radio" name="entry.1346467970" id="group_1346467970_2" value="0-1%">
0-1%
</label>
<label class="radio">
<input type="radio" name="entry.1346467970" id="group_1346467970_3" value="2-10%">
2-10%
</label>
<label class="radio">
<input type="radio" name="entry.1346467970" id="group_1346467970_4" value="11-30%">
11-30%
</label>
<label class="radio">
<input type="radio" name="entry.1346467970" id="group_1346467970_5" value="31-60%">
31-60%
</label>
<label class="radio">
<input type="radio" name="entry.1346467970" id="group_1346467970_6" value="61-99%">
61-99%
</label>
<label class="radio">
<input type="radio" name="entry.1346467970" id="group_1346467970_7" value="100%">
100%
</label>
</div>
</div>
<div class="control-group">
<label class="control-label" for="entry_5829546">
<strong>Comments</strong>
</label>
<div class="controls">
<textarea rows="5" name="entry.5829546" id="entry_5829546" placeholder="Text input"
class="input-xlarge"></textarea>
</div>
</div>
</fieldset>
<fieldset>
<legend>Placard Decision</legend>
<div class="alert alert-info">
Choose a posting based on the evaluation and inspection team judgement.
<ul>
<li>Severe conditions affecting the whole building are grounds for an UNSAFE posting.</li>
<li>Localised Severe and overall Moderate conditions may require a RESTRICTED USE posting.</li>
<li>Place INSPECTED placard at main entrance. Post all other placards at every significant entrance.</li>
</ul>
</div>
<div class="control-group">
<label class="control-label" for="entry_1824267896">
<strong>Building Status</strong>
<span class="ss-required-asterisk">*</span>
</label>
<div class="controls">
<label class="radio">
<input type="radio" name="entry.284968588" id="group_284968588_1" value="INSPECTED - GREEN">
INSPECTED - GREEN
</label>
<label class="radio">
<input type="radio" name="entry.284968588" id="group_284968588_2" value="RESTRICTED USE - YELLOW">
RESTRICTED USE - YELLOW
</label>
<label class="radio">
<input type="radio" name="entry.284968588" id="group_284968588_3" value="UNSAFE - RED">
UNSAFE - RED
</label>
</div>
</div>
<div class="control-group">
<span class="help-block alert alert-info">Tick the boxes below only if further actions are recommended</span>
<label class="control-label" for="entry_1656597785">
<strong>Record any restriction on use or entry</strong>
</label>
<div class="controls">
<label class="checkbox">
<input type="checkbox" name="entry.807765919" id="group_807765919_1"
value="Barricades are needed (state location)">
Barricades are needed (state location)
</label>
<label class="checkbox">
<input type="checkbox" name="entry.807765919" id="group_807765919_2"
value="Level 2 or Detailed Engineering Evaluation recommended">
Level 2 or Detailed Engineering Evaluation recommended
</label>
<label class="checkbox">
<input type="checkbox" name="entry.807765919" id="group_807765919_3"
value="Other recommendations, comments">
Other recommendations, comments
</label>
</div>
</div>
</fieldset>
<div class="form-actions">
<input type="submit" name="submit" value="Submit" id="ss-submit" class="btn btn-primary pull-right"/>
</div>
<input type="hidden" name="draftResponse" value="[]">
<input type="hidden" name="pageHistory" value="0">
</form>
</div>
</div>
<script type='text/javascript' src='/static/forms/client/js/3090771720-formviewer_prd.js'></script>
<script type="text/javascript">_initFormViewer();</script>
</div>
</body>
</html>