NATIONAL TRUST

OUR HERITAGE AT RISK NOMINATION 2008

1.         IDENTIFICATION / LOCATION OF HERITAGE AT RISK

Current Name of Place/Object:                    

Other Names:                                    

Street Address of Place/Object:                   

Local Government Authority:          

Title Details: Lot No:            Vol:    Fol:

UTM Map Reference:          Sheet:                                     Date:              

Eastings:                                 Northings:

Latitude:                                 Longitude:

Type of Place/Object:

Original Owner:                                 

Current Owner -  Name:                                                       

  Address:                  

Current Occupant:                            

Architect/Designer:                            Builder:

Construction Date:                             Alteration/Additions Date:

Original Use:                                      Current Use:

2.         IDENTIFICATION OF CURRENT RISK

Statement of Risk: (a summary of the nature of the risk building on the three criteria below (degree/type/fate)(50 words maximum)

Degree of Risk: (one of)

□*****           Immediate risk – no solution agreed

□****             Immediate risk – solution agreed but not yet implemented

□***               At risk – no solution agreed

□**                 At risk – solution agreed but not implemented

□*                   At risk?????????

Threats/Risks: (one of)

□*****         Destruction                  

□****           Deterioration

□***              Devaluation                 

□**               Damage

□*               Disturbance

Fate/outcome

□*****           Saved (and secure, ie, solution agreed & implemented)

□****             Stable (not yet saved or secure, ie, solution not yet fully implemented)

□***               Surviving

□**                 Suffering

□*                   Stuffed (shattered or smashed )

3.         STATEMENT OF SIGNIFICANCE

            Statement of Significance (50 words maximum)

            Elaboration of Criteria as Applicable (if required to substantiate significance)

·        Aesthetic

·        Historic

·        Scientific

·        Social

·        Spiritual

• Representativeness
• Authenticity
• Rarity

4.         CURRENT HERITAGE RECOGNITION

National List:                                        (date entered)  (ID or Ref number)

Commmonwealth List:

Register of National Estate:

State Heritage Register/Listing:

National Trust Classification:

Municipal Listing/Town Planning Scheme:

Other:

5.         DESIRED OUTCOME / VISION

(What would you like to see happen to the place or object if the threat could be removed)

6.         PHOTOGRAPHS / DOCUMENTATION

                        (max 5 photographs/documents)

Bibliography

7.         RISK/AMELIORATION REPORT CARD

            Year:

            Action:

            Change in Status:

Rating: