1. Location where earthquake effects were observed. (Example: Farm located 3 miles south of Anytown, Minnesota, on county Rd- 7Z. 2 miles south of intersection with State Road YY). Also, if possible, plot approximate location where you observed the effects on the attached map.

2. How were you situated when you made the observation? (Standing. sitting, lying down, etc.). If inside building, what floor were you on? If in a vehicle, was it sitting still or moving?

3. What did you observe? (use back of sheet if necessary)

4. At what time and for how long did you observe these. effects?

5. Was there any noise? If so, what was it like and how long did it last?

6. Describe any damage caused by the quake (examples: cracked foundations, cracked chimneys, items shaken off shelves, etc.).

7. Did you notice any other earthquake-like events after the main quake? If so, describe and estimate date and time (approximate if not certain, give time with AM or PM).

If you need more room, write on the back of this sheet. If you have any other comments or want more information, please contact: Val W. Chandler, Minnesota Geological Survey, 2642 University Ave., St: Paul, Minnesota 55114-1057. Ph. 612-627-4780.