Rapid ATC 20 C.01.08.b Evaluation Safety Assessment Form

User Manual: ATC-20

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ATC-20 Rapid Evaluation Safety Assessment Form
Inspection
Inspector ID:

Inspection date and time:
Areas inspected:

Affiliation:
Building Description
Building name:

AM

Exterior only

PM

Exterior and interior

Type of Construction

Wood frame
Steel frame
Tilt-up concrete
Concrete frame

Address:

Concrete shear wall
Unreinforced masonry
Reinforced masonry
Other: _______________

Building contact/phone:
Number of stories above ground:

below ground:

Primary Occupancy

Government
Commercial
Offices
Historic
Industrial
School
Other: _______________

Dwelling
Other residential
Public assembly
Emergency services

Approx. “Footprint area” (square feet):
Number of residential units:
Number of residential units not habitable:

Evaluation
Investigate the building for the conditions below and check the appropriate column.
Observed Conditions:

Minor/None

Moderate

Estimated Building Damage
Severe

Collapse, partial collapse, or building off foundation
Building or story leaning
Racking damage to walls, other structural damage
Chimney, parapet, or other falling hazard
Ground slope movement or cracking
Other (specify)

(excluding contents)
None
0–1%
1–10%
10–30%
30–60%
60–100%
100%

Comments:

Posting
Choose a posting based on the evaluation and team judgment. Severe conditions endangering the overall building are grounds for
an Unsafe posting. Localized Severe and overall Moderate conditions may allow a Restricted Use posting. Post INSPECTED
placard 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:

Other recommendations:
Comments:

© Copyright 1995-07, Applied Technology Council.
Permission is granted for unlimited, non-exclusive, non-commercial use and distribution of ATC evaluation forms, provided that this Copyright Notice appears on all copies and the Applied
Technology Council name shall not be used in any advertising or publicity of Licensee product. Permission is further subject to the following conditions: (1) Licensee does not reprint, repackage
or offer this form for sale or license; and (2) no material gain or financial profit is to be made from any sale or license of this form. Placards may be used without restrictions for their intended use
as building postings. All rights not specifically granted to Licensee are herein reserved by ATC.



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