BLS-Green Form Pan BLS-Green Form Panel 3

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Green Goods and Services Survey U.S. Department of Labor

O.M.B. No. 1220−0181 Expires September 30, 2010

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lease return this form within 7 days. If you need help completing this form, contact information is listed

on the last page. Thank you!

^{UI (10 digits)}

^{Statename (FIPS)}

Please report for the worksite in using Unemployment Insurance account number

1

Is this the address where this 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 ______________________________________________

2

What is this 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

Does this worksite produce products or services that meet one or more of the following green goods and services categories?

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

Examples of activities included in the green goods and services categories are on the back of the cover letter.

G reen Goods and services are goods and services produced by a firm that benefit the environment or conserve natural resources. Green goods and services categories are below:

• Renewable energy: includes research and development, and the production, installation, operation, and maintenance of energy from renewable sources

• E

  Do any of this worksite’s products or services meet any of these categories?

  
  

  Yes

  
  

  No

  nergy efficiency: includes research and development, and the production, installation, operation, and maintenance of goods and services that improve energy efficiency

• P ollution and greenhouse gas reduction, pollution clean-up, and recycling and reuse: includes research and development, and the production, installation, operation, and maintenance of goods and services that reduce or eliminate the creation, emission, or environmental release of toxic compounds or pollutants, or remove pollutants or hazardous waste from the environment

• Natural resources conservation: includes research and development, and the production, installation, operation, and maintenance of goods and services that conserve natural resources

• Education, compliance, public awareness, and training products and services to develop, implement, and enforce environmental regulations; to provide education and training in the development or application of “green” technologies and practices; and to increase public awareness of environmental issues

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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 15 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.

Does this worksite produce products or services that meet one or more of the following environmental standards or are listed in any of the following environmental programs?

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  lease indicate yes or no for each item

Environmental Standards or Programs:	Yes	No	Environmental Standards or Programs:	Yes	No	Environmental Standards or Programs:	Yes	No
EnergyStar			BurnWise			NSF/ANSI 140: Sustainability Assessment for Carpet
USDA certified organic			EPA environmentally preferable purchasing program			NSF/ANSI 332: Sustainability Assessment Standard for Resilient Floor Covering
USDA BioPreferred listed products			Leadership in Energy and Environmental Design (LEED) projects and eligible products			ANSI/BIFMA X7.1 standards for low-emitting office furniture
Design for the Environment			EPEAT/IEEE (IEEE 1680)			BIFMA e3-2008 Furniture Sustainability Standard
WaterSense			ISO 21930:2007: Environmental declaration of building products			UL Environment
SmartWay			ISO/IEC 24700:2005: Quality and performance of office equipment containing reused components			Other (please specify):

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What percent of this worksite’s total revenue comes from products

%

or services where the primary purpose falls into the categories checked

‘yes’ in question 3 and/or question 4?

Estimate Percent of Total Revenue for:

• Your worksite in Item 1 and fiscal year listed in Item 2.

• If none, enter “0” and return the survey.

• Exclude internal environmental improvements or programs (for example, do not include an internal recycling program)

• For government, education, and non-profits, please provide the percent of the worksite’s total expenditures.

6

How many employees are at this worksite?

Number of employees for pay period that includes March 12, 2010

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 March 12, 2010 for the worksite listed in Item 1. Exclude contractors and workers

hired through temporary help services agencies.

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What is your contact information? Please complete for the person or persons who completed this form.

1. Primary contact’s name: _____________________________________

Title:_________________________________

Phone: (______)________ - ___________ email:_______________________________

Business website:_____________________

2. Secondary contact’s name: ____________________________________

Title:_________________________________

Phone: (______)________ - ___________

email:______________________________

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Do you have any questions about completing this form? For questions, please send an email to [email protected],

or call (202)-691-5185.

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