A modification of a University of Michigan form, this survey form is designed to obtain information on a freestanding library unit for preservation. The questionnaire covers the following areas: (1) library facility construction--e.g., primary building materials, characteristics of the foundation and roof, recent problems; (2) heating and cooling systems--e.g., proximity of library materials to heating and cooling sources, incidence of dampness and mold; (3) plumbing--e.g., proximity of library materials to pipes, water leaks; (4) security--e.g., types of security systems, incidence of break-ins, security awareness programs; (5) fire hazards--e.g., staff familiarity with alarms and extinguishers, electric problems, flammable materials stored in the building; (6) collections--e.g., location of stacks in relation to walls, proximity of stacks to automated sprinkler runoff; and (7) disaster planning--e.g., availability of up-to-date floor plans, master electrical switches, evacuation plans and staff emergency teams. (SD)