Form NCS 11-1P NCS 11-1P Establishment Collection Form for Private Industry

National Compensation Survey

11-1P 2011EstabmentformPrivind

National Compensation Survey (Private Industry Sample)

OMB: 1220-0164

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U.S. Department of Labor

Bureau of Labor Statistics


National Compensation Survey


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. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate and timely.

Form Approved

O.M.B. #1220-0164

Expires 1/31/14

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 PRIVATE INDUSTRY



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 11-1P (September 2010)

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:

FOR PRIVATE ESTABLISHMENTS ONLY:

Is the establishment profit or non-profit? Profit Non-profit



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 Modified2010-09-09
File Created2007-06-30

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