Attachment 1 - NCS Joint Colection Phase 2 Checklist Strategy Collection Tool

Schedule Number
Establishment Information
Establishment Name

Start Time

Address

Actual NAICS

Respondent 1
Name

Total Employment
Respondent 2
Name

Title

Title

Phone

Phone

Email
Facility Type

Email
Product /Service

Selected Occupations
1

End Time

Assigned NAICS

Observed?
Yes/ No 5

Observed?
Yes/ No

2

Yes/ No 6

Yes/ No

3

Yes/ No 7

Yes/ No

4

Yes/ No 8

Yes/ No

Private Industry sample Establishments:
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.

O.M.B. # 1220-0164
Expires 4/30/15

We estimate that it will take an average of 60 minutes to complete this interview, 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.
State and Local Government sample Establishments:
The BLS publishes statistical tabulations from this survey that may reveal the information reported
by individual State and local governments. Upon your request, however, the BLS will hold the
information provided on this survey form in confidence.

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.

O.M.B. # 1220-0164
Expires 4/30/15

We estimate that it will take an average of 60 minutes to complete this interview, 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.

Quote 1 Title
Job Details
Job Code:
Primary SOC:
Secondary SOC:
Work Schedule ___ /___ /___
( FT / PT ) ( U / N )( T / I )
( Non-Supv / Lead / Supv )
Work Setting:

Employment
Leveling
JC&C:

Contacts:

Education, Training & Experience
Degree:
Literacy:
Training, Licenses, or Cert:
Time:
Prior Work Experience:
OJT/Mentoring/Other:

Sitting & Standing/Walking
Sitting
Standing/Walking
Sit/Stand-Walk at will? Yes/No
Keyboarding
Traditional Keyboard
10-Key
Touch Screen
Other (document)
Other Office Tasks
Writing
Telephone Use
Hearing & Vision Requirements
Comm. Verbally
Hear & Understand Conv. Speech Yes/No
Hear & Respond to Signals Yes/No
Near Visual Acuity Yes/No
Far Visual Acuity Yes/No
Peripheral Vision Yes/No
Manipulation
One/Both
Fine
One/Both
Gross
Lifting/Carrying
Most Weight Ever
lbs
More than 2/3 of time
lbs
1/3 to 2/3 of time
lbs
Seldom to 1/3 of time
lbs
Seldom
lbs
Reaching
One/Both
Overhead
One/Both
At/below shoulder
Begin
levelYes/No Questions
Driving
Y/N If NO skip to Push/Pull
Time
Vehicle Type
Transmission Type
Push/Pulling
Y/N If NO skip to Foot/Leg
Ctrl)
One/Both
Hand/Arm
One/Both
Foot/Leg
One/Both
Feet Only
One/Both
Foot/Leg Controls
If
NO
skip
to
Crawling
Get Low?
Y/N
Stooping
Crouching
Kneeling
Crawling
Climb Ramps/Stairs
Related to Structure? Yes/No
Climb Ladder/Ropes/Scaffold

Quote 2 Title
Job Details
Job Code:
Primary SOC:
Secondary SOC:
Work Schedule ___ /___ /___
( FT / PT ) ( U / N )( T / I )
( Non-Supv / Lead / Supv )
Work Setting:

Employment
Leveling
JC&C:

Contacts:

Education, Training & Experience
Degree:
Literacy:
Training, Licenses, or Cert:
Time:
Prior Work Experience:
OJT/Mentoring/Other:

Sitting & Standing/Walking
Sitting
Standing/Walking
Sit/Stand-Walk at will? Yes/No
Keyboarding
Traditional Keyboard
10-Key
Touch Screen
Other (document)
Other Office Tasks
Writing
Telephone Use
Hearing & Vision Requirements
Comm. Verbally
Hear & Understand Conv. Speech Yes/No
Hear & Respond to Signals Yes/No
Near Visual Acuity Yes/No
Far Visual Acuity Yes/No
Peripheral Vision Yes/No
Manipulation
One/Both
Fine
One/Both
Gross
Lifting/Carrying
Most Weight Ever
lbs
More than 2/3 of time
lbs
1/3 to 2/3 of time
lbs
Seldom to 1/3 of time
lbs
Seldom
lbs
Reaching
One/Both
Overhead
One/Both
At/below shoulder
Begin
levelYes/No Questions
Driving
Y/N If NO skip to Push/Pull
Time
Vehicle Type
Transmission Type
Push/Pulling
Y/N If NO skip to Foot/Leg
Ctrl)
One/Both
Hand/Arm
One/Both
Foot/Leg
One/Both
Feet Only
One/Both
Foot/Leg Controls
If
NO
skip
to
Crawling
Get Low?
Y/N
Stooping
Crouching
Kneeling
Crawling
Climb Ramps/Stairs
Related to Structure? Yes/No
Climb Ladder/Ropes/Scaffold

Quote 3 Title
Job Details
Job Code:
Primary SOC:
Secondary SOC:
Work Schedule ___ /___ /___
( FT / PT ) ( U / N )( T / I )
( Non-Supv / Lead / Supv )
Work Setting:

Employment
Leveling
JC&C:

Contacts:

Education, Training & Experience
Degree:
Literacy:
Training, Licenses, or Cert:
Time:
Prior Work Experience:
OJT/Mentoring/Other:

Sitting & Standing/Walking
Sitting
Standing/Walking
Sit/Stand-Walk at will? Yes/No
Keyboarding
Traditional Keyboard
10-Key
Touch Screen
Other (document)
Other Office Tasks
Writing
Telephone Use
Hearing & Vision Requirements
Comm. Verbally
Hear & Understand Conv. Speech Yes/No
Hear & Respond to Signals Yes/No
Near Visual Acuity Yes/No
Far Visual Acuity Yes/No
Peripheral Vision Yes/No
Manipulation
One/Both
Fine
One/Both
Gross
Lifting/Carrying
Most Weight Ever
lbs
More than 2/3 of time
lbs
1/3 to 2/3 of time
lbs
Seldom to 1/3 of time
lbs
Seldom
lbs
Reaching
One/Both
Overhead
One/Both
At/below shoulder
Begin
levelYes/No Questions
Driving
Y/N If NO skip to Push/Pull
Time
Vehicle Type
Transmission Type
Push/Pulling
Y/N If NO skip to Foot/Leg
Ctrl)
One/Both
Hand/Arm
One/Both
Foot/Leg
One/Both
Feet Only
One/Both
Foot/Leg Controls
If
NO
skip
to
Crawling
Get Low?
Y/N
Stooping
Crouching
Kneeling
Crawling
Climb Ramps/Stairs
Related to Structure? Yes/No
Climb Ladder/Ropes/Scaffold

Quote 4 Title
Job Details
Job Code:
Primary SOC:
Secondary SOC:
Work Schedule ___ /___ /___
( FT / PT ) ( U / N )( T / I )
( Non-Supv / Lead / Supv )
Work Setting:

Employment
Leveling
JC&C:

Contacts:

Education, Training & Experience
Degree:
Literacy:
Training, Licenses, or Cert:
Time:
Prior Work Experience:
OJT/Mentoring/Other:

Sitting & Standing/Walking
Sitting
Standing/Walking
Sit/Stand-Walk at will? Yes/No
Keyboarding
Traditional Keyboard
10-Key
Touch Screen
Other (document)
Other Office Tasks
Writing
Telephone Use
Hearing & Vision Requirements
Comm. Verbally
Hear & Understand Conv. Speech Yes/No
Hear & Respond to Signals Yes/No
Near Visual Acuity Yes/No
Far Visual Acuity Yes/No
Peripheral Vision Yes/No
Manipulation
One/Both
Fine
One/Both
Gross
Lifting/Carrying
Most Weight Ever
lbs
More than 2/3 of time
lbs
1/3 to 2/3 of time
lbs
Seldom to 1/3 of time
lbs
Seldom
lbs
Reaching
One/Both
Overhead
One/Both
At/below shoulder
Begin
levelYes/No Questions
Driving
Y/N If NO skip to Push/Pull
Time
Vehicle Type
Transmission Type
Push/Pulling
Y/N If NO skip to Foot/Leg
Ctrl)
One/Both
Hand/Arm
One/Both
Foot/Leg
One/Both
Feet Only
One/Both
Foot/Leg Controls
If
NO
skip
to
Crawling
Get Low?
Y/N
Stooping
Crouching
Kneeling
Crawling
Climb Ramps/Stairs
Related to Structure? Yes/No
Climb Ladder/Ropes/Scaffold

Quote 5 Title
Job Details
Job Code:
Primary SOC:
Secondary SOC:
Work Schedule ___ /___ /___
( FT / PT ) ( U / N )( T / I )
( Non-Supv / Lead / Supv )
Work Setting:

Employment
Leveling
JC&C:

Contacts:

Education, Training & Experience
Degree:
Literacy:
Training, Licenses, or Cert:
Time:
Prior Work Experience:
OJT/Mentoring/Other:

Sitting & Standing/Walking
Sitting
Standing/Walking
Sit/Stand-Walk at will? Yes/No
Keyboarding
Traditional Keyboard
10-Key
Touch Screen
Other (document)
Other Office Tasks
Writing
Telephone Use
Hearing & Vision Requirements
Comm. Verbally
Hear & Understand Conv. Speech Yes/No
Hear & Respond to Signals Yes/No
Near Visual Acuity Yes/No
Far Visual Acuity Yes/No
Peripheral Vision Yes/No
Manipulation
One/Both
Fine
One/Both
Gross
Lifting/Carrying
Most Weight Ever
lbs
More than 2/3 of time
lbs
1/3 to 2/3 of time
lbs
Seldom to 1/3 of time
lbs
Seldom
lbs
Reaching
One/Both
Overhead
One/Both
At/below shoulder
Begin
levelYes/No Questions
Driving
Y/N If NO skip to Push/Pull
Time
Vehicle Type
Transmission Type
Push/Pulling
Y/N If NO skip to Foot/Leg
Ctrl)
One/Both
Hand/Arm
One/Both
Foot/Leg
One/Both
Feet Only
One/Both
Foot/Leg Controls
If
NO
skip
to
Crawling
Get Low?
Y/N
Stooping
Crouching
Kneeling
Crawling
Climb Ramps/Stairs
Related to Structure? Yes/No
Climb Ladder/Ropes/Scaffold

Quote 6 Title
Job Details
Job Code:
Primary SOC:
Secondary SOC:
Work Schedule ___ /___ /___
( FT / PT ) ( U / N )( T / I )
( Non-Supv / Lead / Supv )
Work Setting:

Employment
Leveling
JC&C:

Contacts:

Education, Training & Experience
Degree:
Literacy:
Training, Licenses, or Cert:
Time:
Prior Work Experience:
OJT/Mentoring/Other:

Sitting & Standing/Walking
Sitting
Standing/Walking
Sit/Stand-Walk at will? Yes/No
Keyboarding
Traditional Keyboard
10-Key
Touch Screen
Other (document)
Other Office Tasks
Writing
Telephone Use
Hearing & Vision Requirements
Comm. Verbally
Hear & Understand Conv. Speech Yes/No
Hear & Respond to Signals Yes/No
Near Visual Acuity Yes/No
Far Visual Acuity Yes/No
Peripheral Vision Yes/No
Manipulation
One/Both
Fine
One/Both
Gross
Lifting/Carrying
Most Weight Ever
lbs
More than 2/3 of time
lbs
1/3 to 2/3 of time
lbs
Seldom to 1/3 of time
lbs
Seldom
lbs
Reaching
One/Both
Overhead
One/Both
At/below shoulder
Begin
levelYes/No Questions
Driving
Y/N If NO skip to Push/Pull
Time
Vehicle Type
Transmission Type
Push/Pulling
Y/N If NO skip to Foot/Leg
Ctrl)
One/Both
Hand/Arm
One/Both
Foot/Leg
One/Both
Feet Only
One/Both
Foot/Leg Controls
If
NO
skip
to
Crawling
Get Low?
Y/N
Stooping
Crouching
Kneeling
Crawling
Climb Ramps/Stairs
Related to Structure? Yes/No
Climb Ladder/Ropes/Scaffold

Quote 7 Title
Job Details
Job Code:
Primary SOC:
Secondary SOC:
Work Schedule ___ /___ /___
( FT / PT ) ( U / N )( T / I )
( Non-Supv / Lead / Supv )
Work Setting:

Employment
Leveling
JC&C:

Contacts:

Education, Training & Experience
Degree:
Literacy:
Training, Licenses, or Cert:
Time:
Prior Work Experience:
OJT/Mentoring/Other:

Sitting & Standing/Walking
Sitting
Standing/Walking
Sit/Stand-Walk at will? Yes/No
Keyboarding
Traditional Keyboard
10-Key
Touch Screen
Other (document)
Other Office Tasks
Writing
Telephone Use
Hearing & Vision Requirements
Comm. Verbally
Hear & Understand Conv. Speech Yes/No
Hear & Respond to Signals Yes/No
Near Visual Acuity Yes/No
Far Visual Acuity Yes/No
Peripheral Vision Yes/No
Manipulation
One/Both
Fine
One/Both
Gross
Lifting/Carrying
Most Weight Ever
lbs
More than 2/3 of time
lbs
1/3 to 2/3 of time
lbs
Seldom to 1/3 of time
lbs
Seldom
lbs
Reaching
One/Both
Overhead
One/Both
At/below shoulder
Begin
levelYes/No Questions
Driving
Y/N If NO skip to Push/Pull
Time
Vehicle Type
Transmission Type
Push/Pulling
Y/N If NO skip to Foot/Leg
Ctrl)
One/Both
Hand/Arm
One/Both
Foot/Leg
One/Both
Feet Only
One/Both
Foot/Leg Controls
If
NO
skip
to
Crawling
Get Low?
Y/N
Stooping
Crouching
Kneeling
Crawling
Climb Ramps/Stairs
Related to Structure? Yes/No
Climb Ladder/Ropes/Scaffold

Quote 8 Title
Job Details
Job Code:
Primary SOC:
Secondary SOC:
Work Schedule ___ /___ /___
( FT / PT ) ( U / N )( T / I )
( Non-Supv / Lead / Supv )
Work Setting:

Employment
Leveling
JC&C:

Contacts:

Education, Training & Experience
Degree:
Literacy:
Training, Licenses, or Cert:
Time:
Prior Work Experience:
OJT/Mentoring/Other:

Sitting & Standing/Walking
Sitting
Standing/Walking
Sit/Stand-Walk at will? Yes/No
Keyboarding
Traditional Keyboard
10-Key
Touch Screen
Other (document)
Other Office Tasks
Writing
Telephone Use
Hearing & Vision Requirements
Comm. Verbally
Hear & Understand Conv. Speech Yes/No
Hear & Respond to Signals Yes/No
Near Visual Acuity Yes/No
Far Visual Acuity Yes/No
Peripheral Vision Yes/No
Manipulation
One/Both
Fine
One/Both
Gross
Lifting/Carrying
Most Weight Ever
lbs
More than 2/3 of time
lbs
1/3 to 2/3 of time
lbs
Seldom to 1/3 of time
lbs
Seldom
lbs
Reaching
One/Both
Overhead
One/Both
At/below shoulder
Begin
levelYes/No Questions
Driving
Y/N If NO skip to Push/Pull
Time
Vehicle Type
Transmission Type
Push/Pulling
Y/N If NO skip to Foot/Leg
Ctrl)
One/Both
Hand/Arm
One/Both
Foot/Leg
One/Both
Feet Only
One/Both
Foot/Leg Controls
If
NO
skip
to
Crawling
Get Low?
Y/N
Stooping
Crouching
Kneeling
Crawling
Climb Ramps/Stairs
Related to Structure? Yes/No
Climb Ladder/Ropes/Scaffold

Environmental Conditions
Quote
Noise Intensity Level–
Quiet Mod Loud Very Loud

6

7

8

Q M L VL

Q M L VL

Q M L VL

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

High, Exposed Places

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Time:
Toxic, Caustic Chemicals

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Outdoors

1

2

3

4

Q M L VL

Q M L VL

Q M L VL

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

5

Q M L VL Q M L VL

Time:
Extreme Heat
non-weather related
Time:
Extreme Cold
non-weather related
Time:
Wetness
non-weather related
Time:
Humidity
non-weather related
Time:
Heavy Vibration
Time:
Fumes, Noxious
Odors, Dusts & Gases
Time:
Proximity to Moving
Mechanical Parts
Time:

Time:
Notes: