Special Collections Declaration Form
Custodian/Responsible Party
Name:
Office Location Rm:
Department:
Daytime Phone:
Office Location Bldg:
After Hours Phone:
Ownership of Collection (If on loan, indicate duration in months)
 UC Owned
 On Loan – Other

Institution, Domestic

Gift - Conditional

On Loan – Other
Institution, Foreign

On Loan – Government,
Domestic

On Loan – Government,
Foreign
Duration of Loan:
Collection Location (Complete all fields)
Building:
Floor:
Room #:
Additional:
Collection Type (Select most appropriate type)
 Archaeological artifacts
 Historic object
 Archival documentation
 Library media
 Cultural material
 Prehistoric object
CAAN:

Religious object

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Scientific specimens
Work of art
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Other :

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Synthetic Chemical
Synthetic Fiber
Tools/Instruments
Upholstered Furniture
Wet Collections

Wood Products

Other :
Open Shelving – Wood
Restrained
Open Shelving – Wood
Unrestrained
Material Type (Select all that apply)
 Agricultural Crop

 Animal Material

 Basket

 Bound Book

 Cabinetry/Furniture

Drape/Tapestry
Electronic Media
Geological Specimen
Human Material
Jewelry

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Carpet/Floor Covering

Linen

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Cellulose Nitrate Film

Magazine

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Ceramics/Pottery
Decoration

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Metal/Ferrous
Metal/Non-Ferrous

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Metal/Precious
Natural Chemical
Natural Fiber
Paper/Newspaper
Photographic Media
Electronic
Photographic Media
Glass
Photographic Media
Paper
Pyroxylin Plastic
Safety Film

Open Display/Storage

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Open Shelving – Metal
Restrained
Open Shelving – Metal
Unrestrained

Method of Storage (Select most descriptive)
 Boxed/Container –
 File Cabinet/Desk Drawer
Cardboard
– Metal
 Boxed/Container - Metal
 File Cabinet/Desk Drawer
– Wood
 Boxed/Container –
 File Cabinet – Fire Rated
Plastic/Wood
 Freezer/Refrig/Climate
Controlled
On Loan - Private Owner

Hazardous Effects (Select all that apply)
 Flame
 Frangible/Friable by
Impact

Light//UV/Solar

Smoke/Soot

Frangible/Friable by Fall

Heat/Temperature

Loss of Power

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Frangible/Friable by
Handling

Humidity

Pressure

Theft/Embezzlement
Potential
Water

Remove from Area Immediate
Remove from Area –
Moderate Delay

Remove from Area –
Extended Delay
Response Triage (Select most appropriate initial response)
 Protect in Place  Protect in Place –
Immediate
Extended Delay
 Protect in Place –
Moderate Delay
EH&S, UCR

2/12/2016