* 1. Name

* 2. Organization Name (if applicable)

* 3. Address

* 4. Email Address

* 5. Phone

* 6. Are you answering this survey on behalf of yourself or on the behalf of an organization?

* 7. If you are answering on behalf of an organization, what is the name of the organization?

* 8. Do you or the organization hold historic materials (collections, papers, artifacts, oral histories, etc.) about disability history in Western Pennsylvania?
If yes, please answer the following questions. If no, please go to question #18.

* 9. Time Period of Historic Materials
Please indicate the time period represented in the historic material held by you or your organization. Check all responses that apply.

* 10. Type of Historic Materials
Please indicate the types of historic materials held by you or your organization. Check all that apply.

* 11. Populations Represented in Historic Materials
Please indicate which of the following disability groups are represented in the historic materials held by you or your organization. Check all responses that apply.

* 12. Use of Historic Materials
Have you or your organization used historic materials related to people with disabilities within the last 10 years? Check all responses that apply.

* 13. Organization of Historic Materials
Please indicate the current manner in which the historic materials are organized.

* 14. Organizational Resources
Please indicate the resources your organization dedicates to the preservation and use of historic materials. Please check all that apply.

* 15. Preservation of Historic Materials
Please indicate the overall preservation of the historic materials owned by you or your organization. Please check all that apply.

* 16. May we contact you for additional information about your historic materials?

* 17. Would you like to receive information about resources for preserving your historic materials or finding a repository for them?

* 18. Would you like to receive ongoing information about the Western Pennsylvania Disability History and Action Consortium?

* 19. Please use this box for comments, questions or additional information.

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