Form NCS 11-1P NCS 11-1P Establishment Collection Form for Private Industry

U.S. Department of Labor Bureau of Labor Statistics

National Compensation 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, 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 1/31/14
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 PRIVATE INDUSTRY

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 11-1P (September 2010)

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:
FOR PRIVATE ESTABLISHMENTS ONLY:
Is the establishment profit or non-profit? Profit Non-profit

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

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