BLS-Green Form 334 Green Form 334513

Green Goods and Services Survey

O.M.B. No. 1220−0181

Expires September 30, 2010

Please return this form within 14 days. If you need help completing this form, contact information is listed on the last page. Thank you!

Statename

UI (10 digits)

Please report for location(s) in using Unemployment Insurance account number

1

What is the address where your business establishment is physically located?

Report data for the location below. If this address is no longer correct, please provide us with an updated address in the space provided.

Enter Physical Location Address Corrections Here

T_name

Phy_addr2

PHY_addr1

Phy_city, Phy_state phy_zip-phy_zip_ext

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2

ave we identified your main business activity correctly?

We have listed below a description of your main business activity at this location. If this description is incorrect, please call 202-691-5185 or email [email protected].

NAICS code: 334513 Instruments and related products manufacturing for measuring, displaying and controlling industrial process variables
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily engaged in manufacturing: Instruments and related devices for measuring, displaying, indicating, recording, transmitting, and controlling industrial process variables These processes may include: Temperature, humidity, pressure, vacuum, combustion, flow, level, viscosity, density, acidity, concentration, and rotation		Glass hydrometers and thermometers for other nonmedical uses Instruments and instrumentation systems for laboratory analysis of samples Instruments for measuring or testing of electricity and electrical signals Medical thermometers Optical alignment and display instruments, optical comparators, and optical test and inspection equipment

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3

hat is your business establishment’s fiscal year?

Please provide us with your fiscal year that includes April 15, 2009 for the location listed in Item 1.

Start of Fiscal Year				End of Fiscal Year
MM	DD	YYYY		MM	DD	YYYY

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4

hat is your business establishment’s employment?

Please provide us with the employment figure you reported on your State’s Quarterly Contributions Report for September 2009 for the location listed in Item 1. This figure is the count of all employees subject to State Unemployment Insurance taxes that worked or received pay for the pay period that included September 12^th, 2009.

Employment for pay period that includes September 12, 2009

5

What is your percent revenue from specific product lines?

In Columns 1 and 3, please estimate the percent of total revenue at the location listed in Item 1 for the following products. Please base your estimate on total revenue for your fiscal year from Item 3. The sum of Columns 1 and 3 should equal 100%.

Note: This section may best be completed by someone at your firm with access to financial data.

Percent of total revenue for fiscal year listed in Item 3
1 Percent of total revenue	2 Product line		3 Percent of total revenue	4 Product line
	Absorption analyzers, industrial process type (e.g., infrared), manufacturing			Liquid concentration instruments, industrial process-type, manufacturing
	Acidity (i.e., pH) instruments, industrial process type, manufacturing			Liquid level instruments, industrial process-type, manufacturing
	Analyzers, industrial process control type, manufacturing			Magnetic flow meters, industrial process-type, manufacturing
	Annunciators, relay and solid-state types, industrial display, manufacturing			Manometers, industrial process-type, manufacturing
	Boiler controls, industrial, power, and marine-type, manufacturing			Measuring instruments, industrial process control-type, manufacturing
	Buoyancy instruments, industrial process-type, manufacturing			Mechanical measuring instruments, industrial process-type, manufacturing
	Chromatographs, industrial process-type, manufacturing			Meters, industrial process control-type, manufacturing
	Combustion control instruments (except commercial, household furnace-type) manufacturing			Moisture meters, industrial process-type, manufacturing
	Controllers for process variables (e.g., electric, electronic, mechanical, pneumatic operation) manufacturing			Panelboard indicators, recorders, and controllers, receiver industrial process-type, manufacturing
	Coulometric analyzers, industrial process-type, manufacturing			Pneumatic controllers, industrial process type, manufacturing
	Data loggers, industrial process-type, manufacturing			Potentiometric instruments (except X-Y recorders), industrial process-type, manufacturing
	Density and specific gravity instruments, industrial process-type, manufacturing			Pressure gauges (e.g., dial, digital), industrial process-type, manufacturing
	Differential pressure instruments, industrial process-type, manufacturing			Pressure instruments, industrial process-type, manufacturing
	Digital displays of process variables manufacturing			Primary elements for process flow measurement (i.e., orifice plates) manufacturing
	Display instruments, industrial process control-type, manufacturing			Primary process temperature sensors manufacturing
	Draft gauges, industrial process-type, manufacturing			Process control instruments, industrial, manufacturing
	Electric and electronic controllers, industrial process-type, manufacturing			Programmers, process-type, manufacturing
	Electrodes used in industrial process measurement manufacturing			Pyrometers, industrial process-type, manufacturing
	Electrolytic conductivity instruments, industrial process-type, manufacturing			Recorders, industrial process control-type, manufacturing
5	Electromagnetic flowmeters manufacturing			Refractometers, industrial process-type, manufacturing
	Flow instruments, industrial process-type, manufacturing			Resistance thermometers and bulbs, industrial process-type, manufacturing
	Fluidic devices, circuits, and systems for process control, manufacturing			Telemetering instruments, industrial process-type, manufacturing
	Gas analyzers, industrial process-type, manufacturing			Temperature instruments, industrial process-type (except glass and bimetal thermometers), manufacturing
	Gas and liquid analysis instruments, industrial process-type, manufacturing			Thermal conductivity instruments, industrial process-type, manufacturing
	Gas chromatographic instruments, industrial process-type, manufacturing			Thermistors, industrial process-type, manufacturing
	Gas flow instrumentation, industrial process-type, manufacturing			Thermocouples, industrial process-type, manufacturing
	Gauges (i.e., analog, digital), industrial process-type, manufacturing			Thermometers, filled system industrial process-type, manufacturing
	Humidity instruments, industrial process-type, manufacturing			Time cycle and program controllers, industrial process-type, manufacturing
	Hydrometers, industrial process-type, manufacturing			Transmitters, industrial process control-type, manufacturing
	Hygrometers, industrial process-type, manufacturing			Turbidity instruments, industrial process-type, manufacturing
	Indicators, industrial process control-type, manufacturing			Turbine flow meters, industrial process-type, manufacturing
	Industrial process control instruments manufacturing			Variable control instruments, industrial process-type, manufacturing
	Infrared instruments, industrial process-type, manufacturing			Viscosimeters, industrial process-type, manufacturing
	Instruments for industrial process control manufacturing			Water quality monitoring and control systems manufacturing
	Level and bulk measuring instruments, industrial process-type, manufacturing			Other (please specify):
	Liquid analysis instruments, industrial process-type, manufacturing			Other (please specify):

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6

hat is your contact information? For the person or persons who helped complete this form.

1. Contact 1’s name: __________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:__________________________________

Business website:______________________________________________

2. Contact 2’s name: ____________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:________________________________

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7

o you have any questions about completing this form?

Please send an email to [email protected], or call (202)-691-5185.

Confidentiality Statement. The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. This report is authorized by law 29 U.S.C.2. Paperwork Reduction Act Statement. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate, and timely. We estimate that completing this form will take an average of 20 minutes. This estimate takes into account time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding this survey, including suggestions for reducing the burden, send them to the Bureau of Labor Statistics, Office of Industry Employment Statistics, Paperwork Reduction Project, 2 Massachusetts Avenue, N.E., Room 4840, Washington, DC 20212. The OMB control number for this voluntary survey is 1220-0181 and expires on September 30, 2010. Without a currently valid number BLS would not be able to conduct this survey.

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