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The Cultural Impact Questionnaire will provide the State Historical Society of Iowa with information about the effects of your project on its proposed site.

Property Name:

Property Number and Street:



State: Zip code:

Contact Person on project:

Telephone (daytime):

E-mail Address:

Please answer the following questions:

1. The project will directly or visually affect one or more buildings, structures or objects 50 years of age or older.
(If you are working on a building, new or old, you may be affecting the ground on which it sits as well as the building itself.)
Yes      No

If you answered "Yes" above, check which kinds of project activities are proposed for the property. You must also submit a photograph and the address of each property.
New Construction
Yard, Sidewalks, Plantings

2. The project will involve excavation:
Yes      No

If you answered "Yes" to question 2, describe the width and depth of the proposed excavation work. (Limit response to ~150 words (~1100 characters) or your printer may not print all text.)
You must also submit a map showing the precise location of the project.


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