Form SW-RF-25 State Wage Records Request Form

OMB Control No.:1220-0NEW

BLS Form No.: SW-RF-25

Bureau of Labor Statistics (BLS)

Confidential Wage Records Data

Request Form

Quarterly Census of Employment and Wages (QCEW)

MOU State Partner Project Coordinator
Name:
Title:
Phone Number:
Email Address:

2. Type of Data Request

Wage records data can be requested in three different forms. For information on the options, please consult the Request Form Instructions.

☐ Macro Data Package: Please complete sections 3 and 4 below.

☐ Micro to Macro Data Package: Please complete sections 3 and 4 below.

☐ Micro Data Package: Please complete all sections.

3. Project Title/Abstract

Please provide a short description of the research project using the requested wage records data, including an explanation of why the wage records are needed.

4. Output Presentation Methods

Where, with whom, and how do you intend to share your cleared outputs?

☐Written Publication ☐ Conference Presentation ☐Internal State Agency Presentation

☐ Government Report ☐Sharing with Special Interest Group(s) ☐ Other, please specify:

5. Data Linkage

A statement as to whether BLS sensitive data will be linked to other data, including a list of any data files that will be linked. New datasets created that contain confidential wage records data may only be used for the project detailed on this form and must be destroyed at the end of the project.

6. Projected Project Timeline

Please include a projected completion date for your research project. The timeline of the project must not extend past the State Partner MOU.

7. Personnel

Please list the names and titles of authorized persons at the time of this request. Additional individuals cannot be added to the list of authorized persons without the prior approval of the BLS. The State Partner Project Coordinator is responsible for seeking approval from the BLS by notifying the Wage Records Team and re-submitting this form with an updated list.

First and Last Name	Title	Email

8. Software

Please list the analytical software that you will use to perform the analysis.

9. Project Methodology

Please provide a description of the proposed hypothesis that will be tested and the empirical methods that will be used for the project. Describe the specific data outputs that will result from the project, including a description of whether the research results will be presented as descriptive statistics or frequencies, or via multivariate analysis such as regression coefficients.

Acceptance Signatures: MOU State Partner (Electronic signatures are acceptable.)
State Partner Project Coordinator (listed in Section 1):
Title:
Program Name:
In signing this form, the State Partner agrees to receive and handle the wage records data in accordance with the terms stated in the Wage Records MOU and in this form. _________________________________ Signature and Date

Acceptance Signatures: BLS (Electronic signatures are acceptable.)
BLS Authorizing Official:
Title:	Division Chief
Program Name:	Administrative Statistics and Labor Turnover
In signing this form, the BLS is authorizing the State Partner to receive the requested data for the project described in this form. _________________________________ Signature and Date

To be Maintained by BLS Wage Records Staff
Date of data delivery:
Date of data destruction:
Research outcome summary:

Paperwork Reduction Act Statement. This information is being collected to allow to the sharing of restricted information on a limited basis to eligible researchers for approved statistical analysis. We estimate that it will take an average of 10 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. Email 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, BLS_PRA_Public@bls.gov.