Form NCS 15-1G NCS 15-1G 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.	O.M.B. #1220-0164 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 (1220-0164), 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

(Work level and scheduling)

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 Form15-1G (2015)

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

NATIONAL COMPENSATION SURVEY - Leveling

Schedule Number:

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

NATIONAL COMPENSATION SURVEY - Leveling

Schedule Number:

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

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION SURVEY - Leveling

Schedule Number:

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

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION SURVEY - Leveling

Schedule Number:

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

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION SURVEY - Leveling

Schedule Number:

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

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION SURVEY - Leveling

Schedule Number:

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

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION SURVEY - Leveling

Schedule Number:

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

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION SURVEY - Leveling

Schedule Number:

Quote:

Occupation:

Establishment Grade:

SOC:

Establishment Rate Range:

Establishment Job Title:

Factor	Level	Education, experience, other comments
KNOWLEDGE
JOB CONTROLS AND COMPLEXITY
CONTRACTS
PHYSICAL ENVIRONMENT

Remarks

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION 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

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION 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

U.S. Department of Labor Bureau of Labor Statistics

National Compensation Survey Leveling Form

NATIONAL COMPENSATION 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

NATIONAL COMPENSATION 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

- 38 -