GTP Fax Survey For Green Technologies and Practices Fax Survey Form

U.S. Department of Labor, Bureau of Labor Statistics

Green Technologies and Practices
Fax Response Form
Send to (xxx) xxx-xxxx
Employers selected for the BLS Green Technologies and Practices Survey are requested to respond within 30 days.
If you have questions please contact us at 1-xxx-xxx-xxxx.
Section 1: Establishment information
105 - 12345678901234567890 Establishment ID Number (from front of survey form)
Company Name and Report For (from front of survey form)
Contact Name and Title (please print)

Today’s Date

Telephone Number (ext)
(
)
-

Fax Number
(
)
-

A. Enter the total number of employees at this location as of August 12, 2011.
B. Describe your main products and services.

Section 2: Green technologies and practices
C. Which of the following green technologies and practices does your business use?
Column A: Check yes, if this technology or practice was used during the pay period including August 12, 2011.
Column B: Check yes, if you had employees on your payroll spend any time involved in this technology or
practice or training other employees at the establishment (exclude contract employees and consultants).

Item

Type of Green Activity

Column A

Column B

Did your
business…?

Did any of your employees
spend time on this?

Energy from renewable sources and energy efficiency
Generate electricity, heat, or fuel from renewable sources
primarily for use within your establishment?
Energy sources include:
1

Wind
Biomass
Geothermal
Solar

Ocean
Hydropower
Landfill gas
Municipal solid waste

Use technologies or practices to improve energy efficiency
within your establishment?

2

Practices include but are not limited to the purchase and use
of:
Energy Star rated appliances
A LEED certified building
Energy efficient lighting
Programmable thermostats
Cogeneration (combined heat and power)
Energy efficient manufacturing equipment

□
□
□

□
□

□
□
□

□
□

Yes
No
Does Not Apply

Yes
No
Does Not Apply

Yes
No

Yes
No

OMB No. 1220-xxxx
Approval expires xx-xx-xxxx
BLS-xxxx FAX

Item

Type of Green Activity

Column A

Column B

Did your
business…?

Did any of your employees
spend time on this?

Greenhouse gas and pollution reduction & removal
Use technologies or practices in your operations to reduce
greenhouse gas emissions through methods other than
those listed in Items 1 and 2.
3

Practices include but are not limited to:
Purchase and use of carbon offsets
Promotion and/or subsidy of green forms of
transportation for employees such as carpools, fuel
efficient vehicles, cycling, or mass transit
Implementation of a telework program for employees
Use practices to either reduce the creation or release of
pollutants or toxic compounds as a result of operations, or to
remove pollutants or hazardous waste from the
environment?

4

Pollutants include but are not limited to:
Carbon monoxide
Heavy metals
Sulfur dioxide
Herbicides
Chlorofluorocarbons(CFCs)
Pesticides
Nitrogen oxides
Radioactive
contamination
Chlorinated hydrocarbons
Recycling, reuse, and natural resource conservation
Use technologies or practices to reduce or eliminate the
creation of waste materials as a result of your operations?

5

Practices include but are not limited to:
Collecting and reusing
Composting solid waste
or recycling waste
Remanufacturing
Managing wastewater
Use technologies or practices in your operations to conserve
natural resources? Please do not include using recycled
inputs in your production processes.

6

7

Practices include, but are not limited to:
Managing land resources
Managing storm water
Conserving soil, water, or wildlife
Implementing organic agriculture or sustainable forestry
practices
Other technologies or practices. Please explain below.

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□

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Yes
No

Yes
No

Does Not Apply

Yes
No

Yes
No

Does Not Apply

Yes
No
Does Not Apply

Yes
No

Yes
No

Yes
No

Does Not Apply

X

Yes

□
□

Yes
No

D. How many employees spent more than half of their time using the green technologies or practices at your establishment
for which you checked yes in Column B?
If the number of employees entered is greater than zero please complete Section 3 (next page).
Otherwise, please fax this form to (xxx) xxx-xxxx. Thank you.
OMB No. 1220-xxxx
Approval expires xx-xx-xxxx
BLS-xxxx FAX

Section 3: Occupations and wages of green employees
E. What are the occupations and wages of the employees who spent more than half of their time using
green technologies or practices?
Provide a job title, brief description of duties, and the annual salary or hourly wage in the space provided.
Report part-time employees at their hourly rate.
If you need more space, please copy this page and fax with the completed report.
NUMBER OF EMPLOYEES IN SELECTED WAGE RANGES
(Report Part-time Workers According to an Hourly Rate)
Hourly

A

B

C

D

E

F

G

H

I

J

K

L

under
$9.25

$9.25 11.49

$11.50
- 14.49

$14.50
- 18.24

$18.25
- 22.74

$22.75
- 28.74

$28.75
- 35.99

$36.00
- 45.24

$45.25
- 56.99

$57.00 71.49

$71.50 89.99

$90.00
and over

under
$19,240

$19,240
23,919

$23,920
30,159

$30,160
37,959

$37,960
47,319

$47,320
59,799

$59,800
74,879

$74,880
94,119

$94,120
118,559

$118,560
148,719

$148,720
187,199

$187,200
and over

A

B

C

D

E

F

G

H

I

J

K

L

2

1

T

Total
Annual Salary

Example:
Hydrologists Research water usage and implement
wastewater treatment plans.

T

3

Job Title:
Job Description:

Job Title:
Job Description:

Job Title:
Job Description:

Job Title:
Job Description:

Job Title:
Job Description:

Thank you. Please fax this report to: (xxx) xxx-xxxx
OMB No. 1220-xxxx
Approval expires xx-xx-xxxx
BLS-xxxx FAX