QSS-2A Quarterly Services Survey

OMB No. 0607-0907: Approval Expires: 08/31/2015
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

QUARTERLY SERVICES SURVEY

FORM

QSS-2A

(DRAFT)

Due Date

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YOUR CENSUS REPORT
IS CONFIDENTIAL. This
report is authorized by law
(Title 13, United States Code,
Sections 131 and 182). Under
Section 9 of the same law, your
report to the Census Bureau is
confidential. It may be seen only
by persons sworn to uphold
the confidentiality of Census
Bureau information and may
be used only for statistical
purposes. The law also provides
that information that you report
cannot be used for taxation,
regulation, or investigation and
are exempt from release under
the Freedom of Information Act.
Further, copies of your response
retained in your files are immune
from legal process.

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(Please correct any errors in name, address, and ZIP Code.)

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GENERAL INSTRUCTIONS

21957014

• Any significant change in this firm's operations should be noted in 8
• For establishments sold or acquired during the quarter(s), report data only for the period the establishments
were operated by this firm
• Estimates are acceptable if book figures are not available
• Enter "0" where applicable
• Report data on an accrual basis
Bil.
Mil.
Thou.
Dol.
• Dollars should be rounded to the nearest dollar
1 030280456
• If a figure is $1,030,280,456 it should be reported as
Include:
• Data for all Services establishments (excluding data for Retail, Wholesale, Manufacturing, Mining, and
Construction operations) as defined by the survey coverage in 1
• Data for auxiliary facilities primarily engaged in supporting services to this firm's establishment(s) such as
warehouses, garages, central administrative offices, and repair services

CONTINUE ON PAGE 2

Form QSS-2A
1

Page 2

(DRAFT)

SURVEY COVERAGE
Did this firm provide the business activities described below?

Yes
No - Specify this firm's business activity

2

Not Applicable.

3

ORGANIZATIONAL CHANGE
A. Did this firm experience any acquisitions, sales, mergers, and/or divestitures in the
Yes
No - Go to

4

B. Which of the following organizational changes occurred in the
Check all that apply. If more than one organizational change occurred during the reporting period, explain in
Month

Acquisition
Merger
Sale

Day

8

.

Year

Date of organizational change . . . . . . . . . . . . . . . .
AND
Enter detailed information below

Divestiture
Name of company

EIN (9 digits)

Address (Number and street, P.O. Box, etc.)

City, town, village, etc.

State

ZIP Code

21957022

4

REPORTING PERIOD
What time period is covered by the data provided in this report?
Calendar quarter

Month

Beginning Date
Day
Year

Other - Report beginning and ending dates . . . . . . . . . . . . . . . . . . . .
End Date
Month

Day

Year

CONTINUE ON PAGE 3

Form QSS-2A
5

Page 3

(DRAFT)

SALES, RECEIPTS, OR REVENUE
Taxable Firms
Include:
• Operating revenue
• Total value of service contracts
• Amounts received for work subcontracted to others
• Revenue from services performed by domestic
locations for foreign parent firms, subsidiaries,
branches, etc.
• Market value of compensation in lieu of cash
• Dues and assessments from members and affiliates
Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, state, or Federal tax agency
• Revenue from a domestic parent organization, or
from franchise locations owned by others
• Rents from and revenue of separately operated
departments, concessions, etc., which are leased to
others
• Revenue from customers for carrying or other credit
charges
• Commissions from vending machine operators
• Revenue of foreign subsidiaries (those located
outside the U.S. , i.e., outside the 50 states, District
of Columbia, U.S. Commonwealth Territories, or
U.S. Possessions)
• Nonoperating revenue such as income from
investments, sales of company-owned real estate
(land and building), or other assets (except
inventory held for resale), securities, gifts, loans,
contributions, or grants
• Revenue from the sale of used equipment
• Installment payments from leasing under capital,
finance, or full-payout leases
• Intracompany transfers
• Interest income

Tax-exempt Firms
Include:
• Operating and nonoperating revenue
• Program service revenue
• Gross sales of merchandise, minus returns and
allowances
• Income from interest, dividends, gross rents
(including display space rentals and share of
receipts from departments operated by other
companies), royalties, and other investments
• Net gains (losses) from the sale of real estate (land
and buildings), investments, or other assets (except
inventory held for resale)
• Gross contributions, gifts, and grants (whether or
not restricted for use in operations)
• Dues and assessments from members and affiliates
• Commissions earned from the sale of merchandise
owned by others (including commissions from
vending machine operators)
• Gross receipts from fundraising activities
Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, state, or Federal tax agency
• Gross receipts of departments or concessions
operated by other companies
• Amounts transferred to operating funds from capital
or reserve funds

$ Bil.

Thou.

Dol.

. . . . . . . .

21957030

What was this firm's revenue in the

Mil.

CONTINUE ON PAGE 4

Form QSS-2A
6

Page 4

(DRAFT)

INPATIENT DAYS AND DISCHARGES
Inpatient Days - The unit of measure in which lodging was provided and services rendered to inpatients.
- A patient who is formally admitted and who is discharged or dies on the same day is counted as one patient day,
regardless of the number of hours the patient occupies a hospital bed. For patients switched from observation to
inpatient status, the patient day count should begin on the day the patient was officially admitted as an inpatient.
For inpatient admissions occurring before the current quarter or extending after the current quarter, record only
those days that occur during the second quarter and exclude days occurring before or after the quarter. Do not
include nursery discharges unless they are related to neonatal intermediate or intensive care units.
Include:
Exclude:
• Inpatient acute and sub-acute days
• Nursery days
• Swing bed days
• Newborn days
• Distinct part unit days
• Skilled nursing facilities days
• Long term care days
Discharges - The termination of the granting of lodging in the hospital and the formal release of the patient
(including patients admitted and discharged on the same day).
- If a patient is discharged from an acute care unit and transferred to a swing bed or distinct part unit, one
discharge would be recorded when the patient is discharged from the acute care unit and a second discharge
recorded when the patient is discharged from the swing bed or distinct part unit. Do not include nursery
discharges unless they are related to neonatal intermediate or intensive care units.
Include:
• Inpatient acute and sub-acute discharges
• Swing bed discharges
• Distinct part unit discharges
• Skilled nursing facility discharges
• Long term care discharges

A. What were this firm's inpatient days in the
B. What were this firm's discharges in the
7

. . . . . . . . . . . . .

OPERATING EXPENSES
Include:
• Payroll and employee benefits
• Supplies used for operating your business, cost of
merchandise sold, and other expenses allocated to
operations during the year
• Contracted or purchased services
• Fees paid to other organizations for fundraising
• Depreciation expenses
• Expenses of locations providing support services
(e.g., repair services, administrative services, etc.)
for your service establishments

21957048

. . . . . . . . . . .

Exclude:
• Taxes (sales, amusement, occupancy, use, or other)
collected directly from customers or clients and paid
directly to a local, state, or Federal tax agency
• Outlays for the purchase of real estate (land and
buildings); for construction; for additions, major
alterations, and improvements to existing facilities;
and all other capital expenditures
• Funds invested
• Interest expense
• Bad debt
• Impairment
• Income taxes
• Assessments (dues) paid to the parent or other
chapters of the same organization
• For establishments engaged in raising funds - funds
transferred to charities or other organizations

$ Bil.

What were this firm's expenses in the

Mil.

Thou.

Dol.

. . . . . . .

CONTINUE ON PAGE 5

Form QSS-2A

Page 5

(DRAFT)

8

REMARKS - Please use this space to explain any significant quarter-to-quarter changes, to clarify responses, or indicate
where data were estimated.

9

CONTACT INFORMATION
Name of person to contact regarding this report (Please print)

21957055

Area code
Telephone

Number

-

Title

Extension

Area code
Fax

Number

-

Website

THANK YOU
for completing your QUARTERLY SERVICES SURVEY.
We suggest you keep a copy for your records.
Public reporting burden for this collection of voluntary information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
ECON Survey Comments 0607-0907, U.S. Census Bureau, 4600 Silver Hill Road, Room EMD-8K122, Washington, DC 20233. You may e-mail comments to
[email protected]; use "ECON Survey Comments 0607-0907" as the subject. PLEASE INCLUDE FORM NAME AND NUMBER IN ALL
CORRESPONDENCE.
Respondents are not required to respond to any information collection unless it displays a valid approval number from the Office of Management and Budget.
This 8-digit number appears in the top right corner on the front of this form.