Visiting Researche Visiting Researcher Questionnaire

OMB No. 1220-0180

Expires xx/xx/xxxx

Visiting Researcher Questionnaire

This questionnaire will assist the Bureau of Labor Statistics (BLS) in determining your eligibility to access confidential microdata through the visiting researcher program and in completing the required paperwork if your project is approved. For multiple researchers applying together, but affiliated with different institutions, one questionnaire should be completed for each institution. Thank you for your cooperation.

Applicant Information

Name:

Title:

Email:

Phone:

Fax:

Mailing Address:

Affiliation with Institution:

Employee or faculty. If so, please specify: Full time Part time

Student. If so, please specify your anticipated graduation date:

Fellowship / Post-Doctoral Appointment. If so, please specify end date:

Other. Please specify:

Will you require access to the confidential information?

Yes

No

If yes, please prove a resume or CV.

Project Information

Title:

BLS Data Set(s):

Non-BLS Data Set(s):

Description of your approach to completing the project within a two-year time period. (For example, you may plan to come to the BLS National Office for three months to do your research all at once, or you may plan to work periodically by coming once a month and researching a week at a time. Also, please detail any special circumstances that may affect your availability to access data. Examples of special circumstances include: grants, visiting professorships, fellowships, leaves of absence, and sabbaticals.)

How will you present your research?

Journal Articles(s)

Dissertation(s)

Conference(s)

Report for Government Agency

Other. Please specify:

Institution Information

Institution Legal Name:

Signing Official: This official must have the authority to enter into legal binding agreements on behalf of your employer or educational institution. For educational institutions, this official may be a President, Vice President, provost, Director of Sponsored Research, Contracts Officer, or a similar official. Note that a Dean or Department Chair will not be accepted.

Name:

Title:

Email:

Phone:

Fax:

Mailing Address:

Sources of Funding

What are the sources of funding (if any) for this project?

Collaboration

Are you collaborating with any other universities or institutions for this project?

Yes

No

If yes

What university / institution?

Please list the names of the collaborators.

Specify if any of those collaborators need access to confidential microdata.

Recipient Project Coordinator

Recipient Project Coordinator: A project coordinator must be an employee of the institution and serves as the main point-of-contact between the BLS and the institution. An applicant may serve as project coordinator unless the applicant is a student.

Check if same as applicant.

If not the same as applicant, please fill out the following information:

Name:

Title:

Email:

Phone:

Fax:

Mailing Address:

Affiliation with Institution:

Full-time employee or faculty

Part-time employee or faculty

Other. Please specify:

Will the recipient project coordinator require access to the confidential information?

Yes

No

If yes, please provide their resume or CV.

Additional Individuals Seeking On-site Access to Confidential Microdata
Please specify any additional individuals who require access to confidential microdata. Attach a resume or CV for each individual.
1	Name:		Title:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:
	Name:		Title:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:
	Name:		Title:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:
	Name:		Title:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:
	Name:		Title:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:

Privacy Act Statement. The information you provide will be used by staff at the Bureau of Labor Statistics (BLS) to determine your eligibility for access to confidential BLS data and for other administrative purposes. Providing the information on this form is voluntary; however, the BLS will not be able to grant access to confidential BLS data without this information. The BLS is authorized to request the information on this form under Title 5, United States Code, Section 301.