Form NCS 04-1G NCS 04-1G Establishment Collection Form for Government

National Compensation Survey

2007EstablishFormGOV

National Compensation Survey (State and local government sample)

OMB: 1220-0164

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U.S. Department of Labor

Bureau of Labor Statistics


National Compensation Survey


The BLS publishes statistical tabulations from this survey that may reveal the information reported by individual State and local governments. Upon your request, however, the BLS will hold the information provided on this survey form in confidence.

This report is authorized by law, 29 U.S.C. 2. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate and timely.

Form Approved

O.M.B. #1220-0164

Expires 12/31/10

We estimate that it will take an average of 19 minutes to complete this form, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this information. If you have any comments regarding this estimate or any other aspect of this survey; including suggestions for reducing this burden, please send them to the Bureau of Labor Statistics, Office of Compensation and Working Conditions (1220-0164), 2 Massachusetts Avenue N.E., Washington, D.C. 20212. You are not required to respond to the collection of information unless it displays a currently valid OMB control number.

ESTABLISHMENT COLLECTION FORM FOR GOVERNMENT



Address # 1.

Physical Address Personal Visit Address Mailing Address


Schedule Number(#):

Company Name:

Secondary Name (Doing Business As):

Address:

City/State/ZIP:

Address # 2.

Physical Address Personal Visit Address Mailing Address


Company Name:

Secondary Name (Doing Business As):

Address:

City/State/ZIP:



Establishment Officials (Contact List)

# 1: Authorizing Supplying

Title:

Telephone #:

FAX #:

E-mail:

Address: 1, 2, or COC. Mail forms to

# 2: Authorizing Supplying

Title:

Telephone #:

FAX #:

E-mail:

Address: 1, 2, or COC. Mail forms to

# 3: Authorizing Supplying

Title:

Telephone #:

FAX #:

Email:

Address: 1, 2, or COC. Mail forms to


NCS Form 04-1G (September 2007)

Central Office Clearance (Complete if clearance and/or data obtained from this source)

Clearance obtained: Schedule (data) obtained:

Company Name:

Address:

City/State/ZIP:





Remarks





































COMPANY DATA

Establishment Information (current data) Schedule #:

State:

Collection Panel:

Sample Number:

Assigned Employment:

Total Employment:

PSO Employment:

NAICS:


Establishment Description:

Product Description:



Collection Information

Field Economist:

Method of Collection:

Collection Date:

Payroll Reference Date:



Respondent waived confidentiality Data obtained electronically


Document obtained (Secondary data source)


Written Permission: Yes, No

Name and Title of Official:

Date of Permission:

Permission on file at RO: Yes, No




Status (IDC Wage)

Establishment Status:

Remarks:


Usable



On strike



Vacant



Temporary non response



Refusal



Out of business



Out of scope



Abolished



No matching jobs



Duplicate





SMG Notification

Reason:

Remarks:

Ownership/NAICS change


Part of assigned unit


Collected unit larger than assigned


Employment +/- 20% of assigned


Employment up – business fluctuations


Sampled employment wrong


SMG chose establishment subsample


Overlap (set by system)


Other discrepancy




Remarks










































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File Typeapplication/msword
File TitleBureau of Labor Statistics
AuthorCarney_P
Last Modified ByCarney_P
File Modified2007-06-30
File Created2007-06-30

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