Change Worksheet

PAPERWORK REDUCTION ACT
CHANGE WORKSHEET
Agency/Subagency: Commerce/Census/SSSD

OMB Control Number
0607-0907

Enter only items that change
Current Record
Agency form numbers(s)

QSS-1(A),
QSS-2(A),
QSS-3(A),
QSS-4(A),
QSS-5(A),

QSS-1(E),
QSS-2(E),
QSS-3(E),
QSS-4(E),
QSS-5(E)

New Record
QSS-1(A), QSS-1(E),
QSS-2(A), QSS-2(E),
QSS-3(A), QSS-3(E),
QSS-4(A), QSS-4(E),
QSS-5(A), QSS-5(E), QSS-1APEO, QSS-1E-PEO

Annual reporting and recordkeeping hour burden
Number of respondents
Total annual responses
Percent of these responses collected
electronically

%

%

Total annual hours
Difference
Explanation of difference
Program change
Adjustment
Annual reporting and recordkeeping cost burden
(in thousands of dollars)
Total annualized Capital/Startup costs
Total annual costs (O&M )
Total annualized cost requested
Difference
Explanation of difference
Program change
Adjustment
Other Change**

Signature of Senior Official or designee:

Date:

For OIRA Use
__________________________
__________________________

**This form cannot be used to extend an expiration date.
OMB 83-C

10/95

The U.S. Census Bureau plans to introduce two new survey forms in its Quarterly Services
Survey (QSS) – the QSS-1A-PEO and QSS-1E-PEO. These new survey forms will be used to
capture specific data for the North American Industry Classification System (NAICS) 561330,
Professional Employer Organizations (PEOs).1
Since 2003, the QSS has collected and published data for NAICS 5613 (Employment Services).
However, due to different interpretations between the QSS revenue reporting instructions and
accounting/record keeping practices of select sampled cases in NAICS 561330, collected data in
NAICS 5613 often contained unstable revenue levels2. As a result, the quarterly revenue levels
have to be adjusted to reflect the correct level for the sampled industry.3
To alleviate this discrepancy, the Census Bureau will create two new survey forms that will
specifically address NAICS 561330. The new forms will request data for:
!
!
!
!

Gross billings/professional service fees
Direct costs of worksite employees
Net Revenue (difference between gross billings/professional fees and direct costs
of worksite employees)
An indicator of whether net revenue is a book figure or estimate

The new survey forms will not cause any adjustment to the current sample size. Currently, the
QSS sample contains 86 cases that will receive the new survey forms. The new forms will not
affect public reporting burden which is approximately 15 minutes per response. The new survey
forms will request data similar to the industry’s public reporting, accounting, and /record keeping
procedures.
This change will be effective June 30th, 20074

1

See attachment A.

2

Revenue reporting instructions are located on page 2 of the QSS-1(A) and QSS-1(E) for
question 3. NAICS 561330 represent, Professional Employer Organizations.
3

All adjusted QSS revenue levels are partially based on reconciliation efforts with the
Service Annual Survey (SAS).
4

Mailout date for the 2nd quarter of 2007.

ATTACHMENT A
OMB No. 0607-0907: Approval Expires: 10/31/2009
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

QUARTERLY SERVICES SURVEY

FORM

CE

U.S.
D

ER
M

EP

U.S. CENSUS BUREAU
E NT OF C
TM
OM
AR

US

R

S

BU

QSS-1A-PEO

EA
EN
UO
F TH E C

NOTICE — Your report to the
Census Bureau is confidential by
law (Title 13, U.S. Code). It may
be seen only by persons sworn to
uphold the confidentiality of Census
Bureau information and may be
used only for statistical purposes.
The law also provides that copies
retained in your files are immune
from legal process.
RETURN COMPLETED FORM TO:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
OR
Fax: 1–800–447–4613
NEED HELP?
Visit our web site:
http://www.census.gov/econhelp/qss
or
Call 1–800–772–7851 between 8:30 a.m.
and 5:00 p.m. EST, Monday through Friday.

INTERNET REPORTING
You may complete this survey online at:
Username:

Password:

(Please correct any errors in name, address, or ZIP Code)

http://www.census.gov/econhelp/qss
using your firm’s unique username and original password. If you
change your password, please keep a record for reference.

1 SURVEY COVERAGE

Does this firm have domestic locations providing the business activities described in the
above survey coverage statement?
01

1
2

Yes – Continue with 2
No – Specify your business activity and continue with 2
02

2 NOT APPLICABLE TO THIS FORM

USCENSUSBUREAU

QSS-1A (4-21-2004)

3

REVENUE

06 $ Bil.

Mil.

Thou.

Dol.

A. Gross billings/professional service fees – Report the professional service fee, or
gross billings, for the company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. Direct costs of worksite employees – Report salaries, wages, employment-related taxes,
benefit premiums, and worker’s compensation insurance costs, for PEO worksite employees . . . . . .

C. NET REVENUE – Difference between lines A and B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
07 1

D. Are the revenues reported in C above book figures or estimates? . . . . . . . . . . . . . . .

4

2

Book figures
Estimates

REPORT PERIODS
1
2

Yes – Continue with 5
No – Provide beginning and ending dates for
the most recent and prior quarters.

Most recent quarter
Month

Day

Year

08

Beginning date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
09

Ending date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

SOURCE OF REVENUE
What percentage of revenue (reported in 3 )
is received from each of the following types
of customers?
Estimates are acceptable if actual data is not available.
10

%

1. Government (local, State, and Federal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11

%

2. Business firms and not-for-profit organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12

%

3. Household consumers and individual users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

qss-2peo-1q (1-23-2007)

100%

Page 2

6

ACQUISITIONS OR MERGERS

14

Name of company acquired or merged with

Number and street
13

1

Yes

2

No

City, State, and ZIP Code

15

Date of acquisition
or merger

Month

Year

16

EIN

–

7

REMARKS – Please use this space for comments or to explain any significant difference between your
current and prior quarter revenue.

8

CONTACT INFORMATION

17

Name of person to contact regarding this report

18

Telephone

Area code Number

20

Extension

E-mail address
19

Fax

Area code Number
21

Company website

THANK YOU
for completing your Quarterly Services Survey.
Public reporting burden for this collection of voluntary information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: Paperwork Project 0607-0907, U.S. Census Bureau, 4700 Silver Hill Road, Stop 1500,Washington,
DC 20233-1500. You may e-mail comments to [email protected]; use "Paperwork Project 0607-0907" as the subject. PLEASE
INCLUDE FORM NAME AND NUMBER IN ALL CORRESPONDENCE. Respondents are not required to respond to any information
collection unless it displays a valid approval number from the Office of Management and Budget. This 8-digit number appears in the top right
corner on the front of this form.

QSS-3 (4-21-2004)

Page 3

ATTACHMENT A
OMB No. 0607-0907: Approval Expires: 10/31/2009
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

CE
ER

U.S.
D

M

EP

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

ENT OF C
TM
OM
AR

US

QSS-1E-PEO

R

S

BU

EA

FORM

EN
U O
F TH E C

NOTICE — Your report to the
Census Bureau is confidential by
law (Title 13, U.S. Code). It may
be seen only by persons sworn to
uphold the confidentiality of Census
Bureau information and may be
used only for statistical purposes.
The law also provides that copies
retained in your files are immune
from legal process.
RETURN COMPLETED FORM TO:
U.S. CENSUS BUREAU
1201 East 10th Street
Jeffersonville, IN 47132-0001
OR
Fax: 1–800–447–4613
NEED HELP?
Visit our web site:
http://www.census.gov/econhelp/qss
or
Call 1–800–772–7851 between 8:30 a.m.
and 5:00 p.m. EST, Monday through Friday.

INTERNET REPORTING
You may complete this survey online at:
Password:

Username:

(Please correct any errors in name, address, or ZIP Code)

http://www.census.gov/econhelp/qss
using your firm’s unique username and original password. If you
change your password, please keep a record for reference.

1 SURVEY COVERAGE

Does this firm have domestic locations providing the business activities described in the
above survey coverage statement?
01

1
2

Yes – Continue with 2
No – Specify your business activity and continue with 2
02

2 FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
Is the Federal Employer Identification Number (EIN) printed in the upper left of the address label the same as
that used for this firm on its latest Employer’s Quarterly Federal Tax Return (Treasury Form 941)?
1
Yes – Go to Item 3
03
2
No – Enter current EIN and date you started reporting payroll under this EIN.
Federal Employer Identification Number (EIN)

Month

Year

05

04

–

USCENSUSBUREAU

QSS-1E (4-21-2004)

Attachment A

3

REVENUE

06 $ Bil.

Mil.

Thou.

Dol.

A. Gross billings/professional service fees – Report the professional service fee, or
gross billings, for the company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. Direct costs of worksite employees – Report salaries, wages, employment-related taxes,
benefit premiums, and worker’s compensation insurance costs, for PEO worksite employees . . . . . .

C. NET REVENUE – Difference between lines A and B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
07 1

D. Are the revenues reported in C above book figures or estimates? . . . . . . . . . . . . . . .

4

2

Book figures
Estimates

REPORT PERIODS
1
2

Yes – Continue with 5
No – Provide beginning and ending dates for
the most recent and prior quarters.

Most recent quarter
Month

Day

Year

08

Beginning date . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
09

Ending date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

SOURCE OF REVENUE
What percentage of revenue (reported in 3 )
is received from each of the following types
of customers?
Estimates are acceptable if actual data is not available.
10

%

1. Government (local, State, and Federal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11

%

2. Business firms and not-for-profit organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12

%

3. Household consumers and individual users . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

qss-2peo-1q (1-23-2007)

100%

Page 2

6

ACQUISITIONS OR MERGERS

14

Name of company acquired or merged with

Number and street
13

1

Yes

2

No

City, State, and ZIP Code

15

Date of acquisition
or merger

Month

Year

16

EIN

–

7

REMARKS – Please use this space for comments or to explain any significant difference between your
current and prior quarter revenue.

8

CONTACT INFORMATION

17

Name of person to contact regarding this report

18

Telephone

Area code Number

20

Extension

E-mail address
19

Fax

Area code Number
21

Company website

THANK YOU
for completing your Quarterly Services Survey.
Public reporting burden for this collection of voluntary information is estimated to average 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: Paperwork Project 0607-0907, U.S. Census Bureau, 4700 Silver Hill Road, Stop 1500,Washington,
DC 20233-1500. You may e-mail comments to [email protected]; use "Paperwork Project 0607-0907" as the subject. PLEASE
INCLUDE FORM NAME AND NUMBER IN ALL CORRESPONDENCE. Respondents are not required to respond to any information
collection unless it displays a valid approval number from the Office of Management and Budget. This 8-digit number appears in the top right
corner on the front of this form.

QSS-3 (4-21-2004)

Page 3