1. No category

RAPID EVALUATION SAFETY ASEESSMENT FORM
Inspection:
Inspection ID: ______________
Organization:______________
Inspection Date and Time: __________________
AM
PM
Area inspected:
Exterior Only
Exterior and interior
Building Description:
Building Name:___________________________
Contact:________________________
Approx "Footprint area"(sq.ft): _________________
Types of Construction
Adobe
Stone in mud
Bamboo
Brick in mud
Type of floor
Flexible
Type of Roof
Flexible
Rigid
Rigid
Stone in cement
Brick in cement
Primary Occupancy:
Residental
Hospital
Educational
Industry
Commercial
Club
Address:
District:_______________________
Municipality/VDC:___________________
ward no._____
tole: ____________
Brick in cement
R.C frame
Government Office
Office Institute
Hotel/Restaurant
Wood frame
Others:_________
Police Station
Mix
Others:………
Evaluation:
Estimated
moderate Severe
building damage
(excluding contents)
none
0-1%
1-10%
10-30%
30-60%
60-100%
100%
Observed conditions:
minor/none
-Collapsed, partially collapsed, or moved of its foundation
-Building or any storey is out of plumb
-Damage to primary structural members, cracking of walls,
or signs of distress present.
-Parapet, chimney, or other falling hazard
-Large fissures in ground, massive ground movement, or
slope displacment.
-Other hazard(specify) eg:tree, power line, etc.
_______________________________________
Comments:_________________________________________________________
Posting : Chossing a posting based on the evaluation and team judgement. Severe conditions endangering the
overall building are grounded for an unsafe posting. Localized severe and overall Moderate conditions may allow a
Restricted Use posting. Post INSPECTED placed at main entrance. Post RESTRICTED USE and UNSAFE placards at all
entrances.
INSPECTED (green placard)
RESTRICTED USE(Yellow placard)
UNSAFE(red placard)
Record any use and entry restrictions exactly as written on placard : ______________________________
_______________________________________________________________________
Further Actions Check the boxes below only if further actions are needed.
Barricades needed in the following areas:
Detailed evaluation recommended:
Structural
Geotechnical
other___________
Comments:_________________________________________________________________________