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Establishment Collection Form for Private Industry
ICR 201603-1220-001 · OMB 1220-0189 · Object 63587601.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Establishment Collection Form for Private Industry |
| Author | Carney, Paul - BLS |
| Last Modified By | Writer |
| File Modified | 2015-05-19 |
| File Created | 2026-11-04 |
| Conversion State | complete |
Extracted Text
U.S. Department of Labor
Bureau of Labor Statistics
Occupational Requirements 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, 31 United States Code §§ 1535/FAR 17.5 of the Economy Act. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate and timely.
O.M.B. #1220-XX
Expires X/XX/XX
We estimate that it will take an average of 54 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-XXXX), 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
(Work level and schedule)
Start Time/End Time:
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
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:
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
OCCUPATIONAL REQUIREMENTS SURVEY - Leveling
Schedule Number:
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Non-supervisory Lead Supervisory
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY - Leveling
Schedule Number:
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Non-supervisory Lead Supervisory
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY - Leveling
Schedule Number:
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Non-supervisory Lead Supervisory
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY - Leveling
Schedule Number:
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Non-supervisory Lead Supervisory
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY - Leveling
Schedule Number:
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Non-supervisory Lead Supervisory
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY - Leveling
Schedule Number:
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Non-supervisory Lead Supervisory
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY - Leveling
Schedule Number:
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Non-supervisory Lead Supervisory
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY - Leveling
Schedule Number:
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Non-supervisory Lead Supervisory
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTRACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY –
Base Leveling Supervisor
Schedule Number:
Supervisor
1st 2nd 3rd Line Supervisor/Manager
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Establishment Job Title:
Highest Level Non-Supervisory Subordinate Position _________________________________________________
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY –
Leveling on Duties and Responsibilities of Supervisor
Schedule Number:
Supervisor
1st 2nd 3rd Line Supervisor/Manager
Quote:
Occupation:
Establishment Grade:
SOC:
Establishment Rate Range:
Establishment Job Title:
Factor
Level
Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY –
Leveling Summary
Schedule Number:
Leveling Factors
QUOTE 1
QUOTE 2
QUOTE 3
QUOTE 4
QUOTE 5
QUOTE 6
QUOTE 7
QUOTE 8
KNOWLEDGE
JOB CONTROLS AND
COMPLEXITY
CONTACTS
PHYSICAL ENVIRONMENT
Remarks
OCCUPATIONAL REQUIREMENTS SURVEY -
Work Schedule
Schedule Number:
Quote #
Work Schedule #
Description/occupation
Hours/day
Hours/week
Weeks/year
Type
For “Work Schedule #” note also if Alternate work schedule (Only needed for index schedules)
Remarks