ORS 15-1P Establishment Collection Form for Private Industry

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. #1220-0189 Expires 8/31/2021
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 (1220-0189), 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:	Sample Number:
Assigned Employment:	Total 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
Refusal
Out of business
Out of scope
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

1^st 2^nd 3^rd 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

1^st 2^nd 3^rd 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

2

ORS Form 15-1P