Form NCS 04-1G NCS 04-1G Establishment Collection Form for Government

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey

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.	Form Approved O.M.B. #1220-0164 Expires 12/31/10
We estimate that it will take an average of 19 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 (1220-0164), 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.

ESTABLISHMENT COLLECTION FORM FOR GOVERNMENT

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

NCS Form 04-1G (September 2007)

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

- 4 -