Preliminary Site Information Questionnaire (PSIQ)

This questionnaire is intended to provide preliminary information to assist in evaluating a property's eligibility for the National Register of Historic Places and/or the Register of Historic Kansas Places. It is not a nomination form. If, on the basis of this information, the property appears to meet the criteria for the national register or state register, a nomination form will be sent to you. If you have any questions about this questionnaire or to receive an e-mail with a digital version in Word, please contact the Cultural Resources Division at 785-272-8681, ext. 240.

Please be sure to include at least six interior, six exterior photographs, and a historic view of the property with this questionnaire. In answering these questions, you may use additional pages as necessary.
Please return the questionnaire to:
The Cultural Resources Division, Kansas State Historical Society, 6425 SW Sixth Ave., Topeka, KS 66615-1099.

Is this nomination being prepared for state register listing only or for national register listing which also incorporates the state register?

______ Kansas Only

______ National

1. Name of Property:

2. Address or description of location:

3. Original Use:

4. Present Use:

5. Date(s) of construction and of any major changes:

6. Name and address of owner:

Name:
Address:
City, State, Zip

7. Original owner or occupant:

8. Architect or builder:

9. Why is the property historically or architecturally important?

10. Briefly describe the property. Describe the original form and any major changes, inside and out, that may have occurred. Be sure to point out any notable features. If the property includes outbuildings or notable landscape features, mention them also.

11. Have there been major ground disturbing activities after construction? (i.e. external foundation work, landscaping, removal of cisterns, outbuildings or such?

12. Provide a list of sources that document the historical significance of the property.

13. Why is register listing being sought?

14. Name, address, and telephone number of person submitting this questionnaire:

Name:
Address:
Address:
City, State, Zip:
Home Phone:
Work Phone:
e-Mail Address:

15. If the person submitting this form is not the property owner, has the owner been contacted and does the owner consent to the consideration of this property for nomination to the national or state register?

16. Submitter's interest in the property:

17. Date questionnaire submitted: