BLS-Green Form Pan BLS-Green Form Panel 2 (Standards)

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 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 ______________________________________________

W

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

3

How 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

4

What percentage of your revenue comes from products or services meeting environmental standards at your worksite?

N

%

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

of total revenue for your worksite in Item 1 from all producing or selling products or services that meet one or more of the environmental standards listed below. Please estimate using revenue from the fiscal year listed in Item 2:

Environmental Standards: Please check all that apply
DOE EnergyStar	EPA BurnWise	ANSI/BIFMA X7.1 standards for low-emitting office furniture
USDA certified organic	EPA environmentally preferable purchasing program	BIFMA e3-2008 Furniture Sustainability Standard
USDA BioPreferred listed products	Leadership in Energy & Environmental Design (LEED) projects and eligible products	NSF/ANSI 140: Sustainability Assessment for Carpet
EPA Design for the Environment	ISO/IEC 24700:2005: Quality and performance of office equipment containing reused components	NSF/ANSI 332: Sustainability Assessment Standard for Resilient Floor Covering
EPA WaterSense	ISO 21930:2007: Environmental declaration of building products	UL Environment
EPA SmartWay	EPEAT/IEEE (IEEE 1680)	Other (please specify):

W

5

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:________________________________

D

6

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.

3