BLS-Green Form Pan BLS-Green Form Panel 2 (No Standards)

udbnum

Green Goods and Services Survey

O.M.B. No. 1220−0181

Expires September 30, 2010

P lease 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 the worksite in using Unemployment Insurance account number

1

Is this the address where your worksite is physically located?

Report data for your worksite located at the address 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

hat is your worksite’s fiscal year?

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

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

H

3

ow many employees are at your worksite?

Please provide us with the number of employees subject to State Unemployment Insurance taxes that worked or received pay for the pay period that includes September 12^th, 2009 for the worksite listed in Item 1. This monthly employment figure should exclude contractors and workers hired through temporary help services agencies.

Number of employees for pay period that includes September 12, 2009

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What percentage of your revenue comes from specific activities at your worksite?

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

o

%

f total revenue for your worksite in Item 1 from producing or selling products or services where the primary purpose falls into at least one of the following categories. Please estimate using revenue from the fiscal year listed in Item 2:

Categories: Please check all that apply

• Renewable energy: research on and development, production, storage, and distribution of energy from renewable sources

• Energy efficiency: research on and development and implementation of energy conservation technologies and practices

• Greenhouse gas reduction: research on and development and implementation of technologies and practices to reduce greenhouse gas emissions through approaches other than renewable energy generation and conservation

• Pollution reduction and cleanup: research on and development and implementation of technologies and practices to reduce the emission of pollutants and remove pollutants/hazardous waste from the environment

• Recycling and waste reduction: research on and development and implementation of technologies and practices to collect and recycle materials and waste water

• Education, compliance, public awareness, and training for the above categories.

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hat is your contact information? Please complete for the person or persons who completed 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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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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