Visiting Researche Visiting Researcher Questionnaire

OMB No. 1220-0180

Bureau of Labor Statistics

Visiting Researcher Questionnaire

This questionnaire will assist the Bureau of Labor Statistics (BLS) in determining your eligibility to access restricted data and in completing the required paperwork if your project is approved. For multiple researchers applying together, but affiliated with different institutions, one questionnaire should be completed for each institution. Thank you for your cooperation.

Applicant Information

Name:

Dr. Mr. Ms.

Title:

Email:

Phone:

Fax:

Mailing Address:

Affiliation with Institution:

Employee or faculty. If so, please specify: Full time Part time

Student. If so, please specify your anticipated graduation date:

Fellowship / Post-Doctoral Appointment. If so, please specify end date:

Other. Please specify:

Will you require access to restricted data?

Yes (please provide a resume or CV)

No

Project Information

Title:

BLS Data Set(s):

Years of BLS Data:

Non-BLS Data Set(s):

Outside Software:

Requested Access Location: (choose one)

BLS Office in Washington, DC FSRDC: ____________________________ Please verify on the BLS website (https://www.bls.gov/rda/home.htm ) that desired data is available for use at the specified FSRDC

Description of your approach to completing the project within a two-year time period. (For example, you may plan to do your research all at once, or you may plan to work periodically a week at a time. Also, please detail any special circumstances that may affect your availability to access data. Examples of include: grants, visiting professorships, fellowships, and sabbaticals.)

How will you present your research?

Journal Articles(s)

Dissertation(s)

Conference(s)

Report for Government Agency

Other, please specify:

Institution Information

Institution Legal Name:

Identify Signing Official: This official must have the authority to enter into legal binding agreements on behalf of your employer or educational institution. For educational institutions, this official may be a President, Vice President, Provost, Director of Sponsored Research, Contracts Officer, or a similar official. Note that a Dean or Department Chair will not be accepted.

Name:

Dr. Mr. Ms.

Title:

Email:

Phone:

Fax:

Mailing Address:

Sources of Funding

What are the sources of funding (if any) for this project?

Collaboration

Are you collaborating with any other universities or institutions for this project?

Yes

No

If yes

What university/institution(s)?

Please list the names of the collaborators.

Specify if any of those collaborators need access restricted microdata.

Recipient Project Coordinator

Recipient Project Coordinator: A project coordinator must be an employee of the institution and serves as the main point-of-contact between the BLS and the institution. An applicant may serve as project coordinator unless the applicant is a student.

Check if same as applicant.

If not the same as applicant, please fill out the following information:

Name:

Dr. Mr. Ms.

Title:

Email:

Phone:

Fax:

Mailing Address:

Affiliation with Institution:

Full-time employee or faculty

Part-time employee or faculty

Other. Please specify:

Will the recipient project coordinator require access to the restricted data?

Yes

No

If yes, please provide their resume or CV.

Additional Individuals Seeking On-site Access to Restricted Microdata
Please specify any additional individuals from your institution who require access to restricted microdata. (For example, student research assistants). Attach a resume or CV for each individual.
1	Name:			Dr. Mr. Ms.
	Title:		Email:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:
	Name:			Dr. Mr. Ms.
	Title:		Email:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:
	Name:			Dr. Mr. Ms.
	Title:		Email:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:
	Name:			Dr. Mr. Ms.
	Title:		Email:
	Affiliation with Institution:
	Employee or faculty. If so, please specify: Full time Part time
	Student. If so, please specify your anticipated graduation date:
	Fellowship / Post-Doctoral Appointment. If so, please specify end date:
	Other. Please specify:

Privacy Act Statement. The information you provide will be used by staff at the Bureau of Labor Statistics (BLS) to determine your eligibility for access to restricted BLS data and for other administrative purposes. In accordance with the Privacy Act of 1974 as amended (5 U.S.C. 552a), details about routine uses can be found in the system of records notice,  DOL/BLS – 21, Data Sharing Agreements Database (81 FR 47418).  Providing the information on this form is voluntary; however, the BLS will not be able to grant access to restricted BLS data without this information. The information provided will be used to draft agreements with your institution, which upon full execution are public records. The BLS is authorized to request the information on this form under Title 5, United States Code, Section 301.

Paperwork Reduction Act Statement. This information is being collected to allow access to restricted information on a limited basis to eligible researchers for approved statistical analysis. We estimate that it will take an average of 30 minutes to complete this form. The responses to this collection of information are voluntary. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the U.S. Department of Labor, Bureau of Labor Statistics, Division of Management Systems, Attention: BLS Clearance Coordinator, 2 Massachusetts Ave., NE, Room 4080, Washington, DC 20212.