Form 1 EC22 Content Respondent Debriefing Sample Economic Censu

Generic Clearance for Questionnaire Pretesting Research

Attachment D

ECON - EC22 Content Respondent Debriefing Research

OMB: 0607-0725

Document [pdf]

Download: pdf | pdf

Location Information

DEFINITION OF ESTABLISHMENT
The reporting unit for this questionnaire is an establishment. An establishment is generally a single physical location where business is conducted or where services or industrial
operations are performed.

MAILING ADDRESS

Please update the mailing address if needed.
ATTN

Name 1

Name 2

Store/Plant Number

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

PHYSICAL LOCATION
Please update the physical location if needed.
(P.O. Box and rural route addresses are not physical locations.)
Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

For Census Bureau Use Only
CFN

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Legal Boundary and Municipality

LEGAL BOUNDARY AND MUNICIPALITY
Is this establishment physically located inside the legal boundaries of the city, town, village, etc.?
Yes
No
No legal boundaries
Do not know
In what type of municipality is this establishment physically located?
City, village, or borough
Town or township
Other
Do not know

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Item 1: Employer Identification Number

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
Is the Employer Identification Number (EIN) used on this establishment's latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

Yes
No

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Item 1: Employer Identification Number - Enter/Update EIN

ITEM 1: EMPLOYER IDENTIFICATION NUMBER
What is this establishment’s 9-digit Employer Identification Number (EIN) used on its latest 2022 Internal Revenue Service Form 941, Employer’s Federal Quarterly Tax Return?

EIN
99-9999999

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Item 2A: Ownership or Control

ITEM 2A: OWNERSHIP OR CONTROL
Is your company owned or controlled by another domestic company?
Yes
No

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Item 2B: Ownership or Control - Voting Stock Validation

ITEM 2B: OWNERSHIP OR CONTROL - VOTING STOCK VALIDATION
Does another domestic company own more than 50 percent of the voting stock of your company?
Yes
No

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Item 2C: Ownership or Control - Management and Policy

ITEM 2C: OWNERSHIP OR CONTROL - MANAGEMENT AND POLICY
Does another domestic company have the power to control the management and policies of your company?
Yes
No

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Item 2D: Ownership or Control - Percent of Voting Stock Held

ITEM 2D: OWNERSHIP OR CONTROL - PERCENT OF VOTING STOCK HELD
What percent of voting stock was held by the owning or controlling company?
Less than 50%
50%

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Item 2E: Ownership or Control - Company Information

ITEM 2E: OWNERSHIP OR CONTROL - COMPANY INFORMATION
What is the name, address, and 9-digit Employer Identification Number (EIN) of the owning or controlling company?
Name of owning or controlling company

Home office address (Number and street)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 2F: Number of Establishments

ITEM 2F: NUMBER OF ESTABLISHMENTS

2022
How many establishments operated under EIN at the end of 2022?

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Item 3A: Operational Status

ITEM 3A: OPERATIONAL STATUS
Which of the following best describes this establishment's operational status at the end of 2022?
In operation
Temporarily or seasonally inactive
Ceased operation
Sold or leased to another operator
Other
Describe

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Item 3A: Operational Status - Ceased Operation Date

ITEM 3A: OPERATIONAL STATUS - CEASED OPERATION DATE
What was the date this establishment ceased operation?
MMDDYYYY
MMDDYYYY



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Item 3A: Operational Status - New Owner or Operator Information

ITEM 3A: OPERATIONAL STATUS - NEW OWNER OR OPERATOR INFORMATION
What date was this establishment sold or leased to a new owner or operator?
MMDDYYYY
MMDDYYYY



What is the name, address, and 9-digit Employer Identification Number (EIN) of this establishment's new owner or operator?
Name of new owner/operator

Mailing Address (Number and Street, P.O. Box,
etc.)

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

EIN
99-9999999

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Item 3B: Months in Operation

ITEM 3B: MONTHS IN OPERATION

2022
What was the number of months in operation during 2022?

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Item 4: Primary Business or Activity

ITEM 4: PRIMARY BUSINESS OR ACTIVITY
Which ONE of the following best describes this establishment's primary kind of business or activity in 2022?
Grocery store

445110 001

Food supermarket

445110 003

Food warehouse club or store

445110 004

Natural or organic food store

445110 005

Convenience food store

445120 001

Convenience store selling gasoline

447110 002

Meat market or ham store

445210 003

Fish (seafood) market

445220 001

Fruit stand, vegetable market (permanent location)

445230 001

Supercenter

452311 201

Liquor store

445310 001

Beer, wine, liquor store

445310 002

Delicatessen, primarily selling meats and a range of grocery items

445110 002

Delicatessen, primarily selling fresh and prepared meats

445210 001

Delicatessen, primarily preparing sandwiches and meals for immediate consumption

722513 004

Bakery, primarily selling goods not baked on premises for carry-out customers

445291 001

Bakery, primarily selling goods baked on premises for carry-out customers (no customer seating)

311811 002

Bakery cafe, primarily selling baked goods for eat-in customers

722515 701

Pizza take and bake store

445299 005

Prepackaged cheese and meat store

445299 001

Dairy products store

445299 002

Ice cream/soft serve shop

722515 101

Candy, nut, confectionery store, little or no preparing on premises

445292 001

Vitamin and food (health) supplement store

446191 001

Coffee, tea, spice store

445299 003

Coffee shop

722515 501

Fast food restaurant

722513 002

Full-service restaurant, patrons order through waiter/waitress service and pay after eating

722511 001

Other primary business or activity

(Describe and click the “Save and Continue” button to search.)

779000 001

Select Sector

Describe primary business or activity

You selected:
9-character Code:
6-digit NAICS:

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General Reporting Guidelines

GENERAL REPORTING GUIDELINES

Reporting Period

Responses should cover calendar year 2022.
If your fiscal year covers at least 10 months of calendar year 2022, you may report by fiscal year on all items EXCEPT payroll.
Calendar year figures for payroll may be available from:
IRS Form 941 (Employer’s Quarterly Federal Tax Return)
IRS Form 944 (Employer’s Annual Federal Tax Return)
If you report by fiscal year, indicate the exact dates of the fiscal year on the submission certification screen.

Providing Estimates

If book figures are not available, estimates are acceptable.
How to Report Dollar Figures:

Dollar figures should be rounded to thousands of dollars. EXAMPLE - DO NOT ENTER DATA
Check
if
None

2022
$

EXAMPLE - if a dollar figure is $2,036,355.25, report 2036:

2036

,000.00

EXAMPLE - DO NOT ENTER DATA
Check
if
None
EXAMPLE - if a dollar figure is "0" (or less than $500.00), check the None box:

2022
$

,000.00

How to Report Percents:

Percents should be rounded to whole percents. EXAMPLE - DO NOT ENTER DATA
2022
39

EXAMPLE - if figure is 38.76% of total sales, report 39:

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Consolidating Data for Multiple Locations

CONSOLIDATING DATA FOR MULTIPLE LOCATIONS

Since multiple locations operate under EIN , report on a consolidated basis (sum the total of each location and combine) for:
Item 5: Sales, Shipments, Receipts, or Revenue
Item 7: Employment, Annual Payroll, and First Quarter Payroll
Item 22: Detail of Sales, Shipments, Receipts, or Revenue
Note:

All other Items should be reported individually for the location listed above.
At the end of the Survey, after Remarks, Item 32: Location List will contain a means for you to report information for each establishment individually.
Name, Store/Plant, Address, Kind of Business
Number of Employees; Annual Payroll; First Quarter Payroll; Sales, Shipments, Receipts, or Revenue

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Item 5: Sales, Shipments, Receipts, or Revenue Additional Information

ITEM 5: SALES, SHIPMENTS, RECEIPTS, OR REVENUE

Check
if
None
What were the total sales of merchandise and other operating receipts?
(Include excise taxes. Exclude sales taxes or other taxes collected.)

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2022
$

,000.00

Item 7: Employment and Payroll Additional Information

ITEM 7: EMPLOYMENT AND PAYROLL

Include:
Full- and part-time employees working at this establishment (including employees working from home) whose payroll was reported on Internal Revenue Service Form 941,
Employer's Quarterly Federal Tax Return, and filed under the Employer Identification Number (EIN)
Exclude:
Temporary staffing obtained from a staffing service
Contractors, subcontractors, or independent contractors
Full- or part-time leased employees whose payroll was filed under an employee leasing company's EIN
Purchased or managed services, such as janitorial, guard, or landscape services
Professional or technical services purchased from another firm, such as software consulting, computer programming, engineering, or accounting services
For further clarification, click the "Additional Information" link above.

A. Employment
Check
if
None

2022

What was the number of employees for pay period including March 12?

B. Payroll before deductions
(Exclude employer's cost for fringe benefits.)
Check
if
None
1. What was the annual payroll?

2. What was the first quarter payroll (January-March 2022)?

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2022
$

,000.00

Item 20: Class of Customer

ITEM 20: CLASS OF CUSTOMER
A. As a general business practice, did this establishment sell to household consumers and individual users in 2022?
Yes
No
B. Were 75% or more of this establishment's sales to retailers/wholesalers/distributors for resale in 2022?
Yes
No
C. Did this establishment require proof of business or professional license from new customers in 2022?
Yes
No
D. What was the estimated percentage of this establishment's total sales by class of customer in 2022?
2022
%

1. Household consumers and individuals

2. Retailers for resale

3. Wholesalers/distributors for resale

4. Repair shops for use in repair work

5. Manufacturing and mining industrial users for use as input goods in production

6. Restaurants, hotels, food services, and contract feeding

7. Businesses for end use in their own operation, not for resale or production

8. Building contractors, heavy construction, and special trade contractors

9. Farmers for use in farm production

10. Governmental bodies (Federal, state, and local)

11. Export sales

12. Other

Describe

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13. TOTAL (Sum of lines 1 through 12 should equal 100%.)

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Item 21: Method of Selling

ITEM 21: METHOD OF SELLING
Which ONE of the following best describes this establishment's primary method of selling in 2022?
Electronic commerce (selling goods or facilitating the sale of goods via the Internet or other electronic means)
Store or display showroom (selling from a fixed or permanent location with physical displays of priced merchandise and/or from a counter)
Warehouse or office (including telephone/fax orders or outside sales representatives)
Mail order
Home shopping via television
Direct selling (selling in a face-to-face manner away from a fixed location, such as house-to-house, party plan, or temporary kiosk sales)
Vending machines
Other
Describe

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what products and services were included?
The products and services listed below are generally associated with your industry.

Please select the products or services that contribute to the sales, shipments, receipts, or revenue of this establishment.

Products or Services not listed? Click the "Search for product/service not listed" button at the bottom of the screen to search for and add each product or service not listed.

Select ALL that apply, at the most detailed level possible.

Description

Select

Product Code

1. Retail sales of fresh meat and poultry
(Report deli meats on line 6a and meats sold in a frozen state on line 7a.)

5000025000

2. Retail sales of fresh fish and seafood
(Report fish and seafood sold in a frozen state on line 7a.)

5000050000

3. Retail sales of fresh fruit and vegetables
(Report frozen fruits and vegetables on line 7a.)

5000075000

4. Retail sales of eggs and dairy (except ice cream)
(Report deli cheeses on line 6a and ice cream and other frozen dairy products on line 7b.)

5000100000

5000125000

6. Retail sales of perishable prepared foods packaged for future consumption
a. Retail sales of delicatessen items, including deli meats and other service delicatessen items (except prepared sandwiches,
dishes, and entrees)

5000150000

5000150003

5000150006

b. Retail sales of soup and salad bars

c. Retail sales of all other perishable prepared foods, including prepared sandwiches, dishes, and entrees

5000150009

5000175000

7. Retail sales of frozen foods

a. Retail sales of frozen foods, excluding ice cream and other frozen dairy products

b. Retail sales of ice cream and other frozen dairy products

8. Retail sales of candy, prepackaged cookies, and snack foods
9. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt, nondairy milk, and egg
and cheese substitutes (Include flour, sugar, fats and oils, coffee, honey, jams and jellies, pasta, and crackers.)

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5000175003

5000175006

5000200000

5000225000

10. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages
11. Sales of bread (white, wheat, rye, etc.) and rolls, bread-type (including English muffins, bagels, and croissants), baked on
premises

12. Sales of soft cakes (snack, fruit, pound, layer, cheese, etc.), baked on premises

13. Sales of pies (fruit, cream, and custard), baked on premises

14. Sales of cookies, wafers, and ice cream cones and cups, baked on premises

15. Sales of other sweet goods (doughnuts, pastries, coffee cakes, etc.), baked on premises

16. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate consumption

17. Meals, snacks, other food items, and beverages prepared for catered events

18. Alcoholic beverages, prepared and served or dispensed for immediate consumption

19. Retail sales of bottled, canned, or packaged alcoholic beverages

a. Retail sales of distilled spirits, including liquor, brandy, and liqueurs

5000250000

2001375000

2001400000

2001425000

2001575000

2001450000

7000025000

7000060000

7000050000

5000300000

5000300003

5000300006

b. Retail sales of wine

5000300009

c. Retail sales of beer and ale
20. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids, and other
smoking supplies

a. Retail sales of tobacco products, electronic cigarettes, and other smoking supplies (excluding cannabis/marijuana)
b. Retail sales of cannabis/marijuana dried buds (pre-rolled or loose) and cannabis-based vapor cartridges and liquids, for medical
and non-medical use

5000325000

5000325003

5000325006

5000275000

21. Retail sales of ice

5000775000

22. Retail sales of household cleaning supplies

a. Retail sales of household soaps, detergents, and cleaners

b. Retail sales of household cleaning supplies, including mops, sponges, brooms, and brushes
23. Retail sales of household paper and plastic products, except tableware (Include paper towels, napkins, etc.)
(Report toilet paper, facial tissues, and sanitary napkins on line 27.)

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5000775003

5000775006

5000825000

24. Retail sales of tableware, kitchenware, cookware, glassware (Include flatware, cutlery, paper and plastic tableware, and pots and
pans.)

25. Retail sales of prescription and nonprescription medicines, vitamins, minerals, and supplements

5000750000

5001350000

5001350003

a. Retail sales of prescriptions

5001350006

b. Retail sales of nonprescription medicines

c. Retail sales of vitamins, minerals, and other dietary supplements

5001350009

26. Retail sales of cosmetics and fragrances (Include face cream, makeup, cologne, and perfume.)
(Report hair care products and nail polish on line 27.)

5001450000

27. Retail sales of personal hygiene supplies (Include hand and foot care products, eye/contact lens care products, oral hygiene
products, deodorants, hair care products, nail polish, toilet paper, facial tissues, sanitary napkins, and disposable diapers.)

5001425000

28. Retail sales of home health care equipment and supplies (Include first aid products and surgical and medical masks.)

5001375000

5001250000

29. Retail sales of pet foods and supplies

30. Retail sales of books (Include audio books and e-books.)

31. Retail sales of magazines and newspapers, including issue format comic books

32. Retail sales of other publications, including greeting cards and calendars

5000925000

5000950000

5000975000

5001725000

33. Retail sales of automotive fuels

34. Retail sales of household fuels, including oil, LP gas, wood, coal

5001750000

5001950000

35. Retail sales of automotive parts and supplies

36. Retail sales of hardware, nonpower hand tools, and other building materials and supplies

37. Retail sales of home lawn and garden goods, excluding cut flowers and indoor potted plants

a. Retail sales of powered lawn and garden tools, equipment, and machinery and parts

5001930000

5000805000

5000805003

5000805006

b. Retail sales of outdoor grills

c. Retail sales of all other lawn and garden supplies, including fencing, irrigation equipment, sprinklers, and garden hoses

d. Retail sales of pools, pool chemicals, and pool supplies and accessories

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5000805009

5000805012

e. Retail sales of outdoor nursery stock, including trees, shrubs, bedding plants, bulbs, sod, seeds, etc.

5000805015

5000810000

38. Retail sales of cut flowers and indoor potted plants

5000810003

a. Retail sales of cut flowers -- unarranged

5000810006

b. Retail sales of cut flowers -- arranged

5000810009

c. Retail sales of indoor potted plants -- blooming

5000810012

d. Retail sales of indoor potted plants -- nonblooming

5000680000

39. Retail sales of other home furnishings and accessories
a. Retail sales of decorative accessories and home furnishings (Include lamps, lampshades, decorative glassware, vases, giftware,
mirrors, pictures, picture frames, clocks, magazine racks, desk sets, closet and bathroom accessories, etc.)

5000680003

5000680006

b. Retail sales of artificial/silk flowers, plants, and trees

c. Retail sales of seasonal decorations (except decorative plates, napkins, and cups)

5000680009

5000375000

40. Retail sales of women's clothing

5000350000

41. Retail sales of men's clothing
42. Retail sales of men's and women's clothing accessories (Include hats, gloves, neckwear, rain accessories, etc.)
(Report costume jewelry on line 46.)

43. Retail sales of costumes, vestments, and unisex clothing

5000450000

5000425000

5000475000

44. Retail sales of footwear and footwear accessories

45. Retail sales of children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including school uniforms

5000400000

5000455000

46. Retail sales of costume and novelty jewelry
47. Retail sales of small household appliances, including mixers; blenders; can openers; toasters; coffee makers; frypans; personal
care appliances, such as hair dryers, curling irons, and shavers; tap water purifiers and filters; etc.

48. Retail sales of window treatments, including rods, poles, and fixtures
49. Retail sales of domestics and other textile home furnishings (except carpet and rugs) (Include furniture coverings, towels, sheets,
blankets, table linens and coverings, etc.)

5000725000

5000625000

5000650000

5000875000

50. Retail sales of televisions, audio and video equipment

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51. Retail sales of audio and video recordings, including purchased downloads (excluding audio books)

52. Retail sales of toys, games, and hobby and craft supplies

5001000000

5001125000

5000900000

53. Retail sales of photographic equipment and supplies

54. Retail sales of fabrics, yarns, and other sewing materials and supplies

5001775000

5001400000

55. Retail sales of glasses and contact lenses

56. Retail sales of hunting, fishing, hiking, and camping equipment

5001075000

5001700000

57. Retail sales of exercise/fitness equipment

58. Retail sales of bicycles and other cycles, all types, except children's sidewalk bikes, and parts and accessories

59. Retail sales of other sporting goods and equipment, excluding sport vehicles

60. Retail sales of household goods, not elsewhere classified

5001025000

5001105000

5000860000

5000860003

a. Retail sales of nonautomotive batteries

5000860006

b. Retail sales of religious goods (except books)

5000860009

c. Retail sales of souvenirs and novelty items
d. Retail sales of baby goods, not elsewhere classified, including bottles, monitors, carriers, swings, collapsible playpens, infant and
booster car seats, etc.

5000860012

5000860015

e. Retail sales of gift cards
61. Retail sales of office and school supplies, packaging and packing materials and supplies, and other general industry and
miscellaneous materials and supplies

5001935000

5001935003

a. Retail sales of office, school, and packaging supplies

b. Retail sales of stationery products, including stationery, pads, looseleaf paper, and related products

c. Retail sales of office paper, including computer printer, copier, and fax paper

5001935006

5001935009

5001935012

d. Retail sales of artists' materials and supplies

5001935015

e. Retail sales of gift wrap, gift bags, and tissue paper

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f. Retail sales of other general industry and miscellaneous materials and supplies

62. Local transportation and delivery of purchased or serviced items, including groceries and prepared food
63. Rental and leasing of nonresidential space in buildings or other facilities, except hosting of coin-operated self-service gambling
machines

5001935018

7011125000

7006575000

7014545000

64. Photofinishing services

65. Rental of pre-recorded cassettes, tapes, discs, or video games

7000950000

7002325000

66. Amusement park and arcade services

7014775000

67. Copying and reproduction services

68. Fax transmission services, except fax broadcasting services

69. Document payment services, such as money order and check cashing services (Exclude traveler's check services.)

7014800000

7005543000

7003915000

70. Traveler's check services

Search for product/service not listed

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Item 22: Detail of Sales, Shipments, Receipts, or Revenue - Continued

ITEM 22: DETAIL OF SALES, SHIPMENTS, RECEIPTS, OR REVENUE
Of the $,000.00 of Sales, Shipments, Receipts, or Revenue reported in Item 5, what was the value for each product or service?
Below are the products and services you previously selected.

Products or Services not listed? Click the "Search for product/service not listed" button at the bottom of the screen to search for and add each product or service not listed.

Description

Value

Product Code

1. Retail sales of fresh meat and poultry
(Report deli meats on line 6a and meats sold in a frozen state on line 7a.)

,000.00

5000025000

2. Retail sales of fresh fish and seafood
(Report fish and seafood sold in a frozen state on line 7a.)

,000.00

5000050000

3. Retail sales of fresh fruit and vegetables
(Report frozen fruits and vegetables on line 7a.)

,000.00

5000075000

4. Retail sales of eggs and dairy (except ice cream)
(Report deli cheeses on line 6a and ice cream and other frozen dairy products on line 7b.)

,000.00

5000100000

,000.00

5000125000

,000.00

5000150003

,000.00

5000150006

,000.00

5000150009

,000.00

5000150000

,000.00

5000175003

,000.00

5000175006

,000.00

5000175000

,000.00

5000200000

5. Retail sales of baked goods packaged for future consumption (Include breads, doughnuts, pastries, and pies.)
(Report candy and prepackaged cookies on line 8 and frozen baked goods on line 7a. Report goods baked on the
premises on lines 11 through 15.)
6. Retail sales of perishable prepared foods packaged for future consumption
a. Retail sales of delicatessen items, including deli meats and other service delicatessen items (except prepared
sandwiches, dishes, and entrees)

b. Retail sales of soup and salad bars

c. Retail sales of all other perishable prepared foods, including prepared sandwiches, dishes, and entrees

Subtotal
7. Retail sales of frozen foods

a. Retail sales of frozen foods, excluding ice cream and other frozen dairy products

b. Retail sales of ice cream and other frozen dairy products

Subtotal

8. Retail sales of candy, prepackaged cookies, and snack foods

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9. Retail sales of food dry goods and other foods purchased for future consumption, including nondairy yogurt, nondairy
milk, and egg and cheese substitutes (Include flour, sugar, fats and oils, coffee, honey, jams and jellies, pasta, and
crackers.)

,000.00

5000225000

,000.00

5000250000

11. Sales of bread (white, wheat, rye, etc.) and rolls, bread-type (including English muffins, bagels, and croissants),
baked on premises

,000.00

2001375000

12. Sales of soft cakes (snack, fruit, pound, layer, cheese, etc.), baked on premises

,000.00

2001400000

,000.00

2001425000

,000.00

2001575000

15. Sales of other sweet goods (doughnuts, pastries, coffee cakes, etc.), baked on premises

,000.00

2001450000

16. Meals, snacks, other food items, and nonalcoholic beverages, prepared and served or dispensed, for immediate
consumption

,000.00

7000025000

,000.00

7000060000

,000.00

7000050000

,000.00

5000300003

,000.00

5000300006

,000.00

5000300009

,000.00

5000300000

a. Retail sales of tobacco products, electronic cigarettes, and other smoking supplies (excluding cannabis/marijuana)

,000.00

5000325003

b. Retail sales of cannabis/marijuana dried buds (pre-rolled or loose) and cannabis-based vapor cartridges and
liquids, for medical and non-medical use

,000.00

5000325006

,000.00

5000325000

,000.00

5000275000

10. Retail sales of bottled, canned, or packaged soft drinks and nonalcoholic beverages

13. Sales of pies (fruit, cream, and custard), baked on premises

14. Sales of cookies, wafers, and ice cream cones and cups, baked on premises

17. Meals, snacks, other food items, and beverages prepared for catered events

18. Alcoholic beverages, prepared and served or dispensed for immediate consumption
19. Retail sales of bottled, canned, or packaged alcoholic beverages

a. Retail sales of distilled spirits, including liquor, brandy, and liqueurs

b. Retail sales of wine

c. Retail sales of beer and ale

Subtotal
20. Retail sales of tobacco products, electronic cigarettes, cannabis/marijuana dried buds, vapor cartridges and liquids,
and other smoking supplies

Subtotal

21. Retail sales of ice
22. Retail sales of household cleaning supplies

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

,000.00

5000775003

,000.00

5000775006

,000.00

5000775000

23. Retail sales of household paper and plastic products, except tableware (Include paper towels, napkins, etc.)
(Report toilet paper, facial tissues, and sanitary napkins on line 27.)

,000.00

5000825000

24. Retail sales of tableware, kitchenware, cookware, glassware (Include flatware, cutlery, paper and plastic tableware,
and pots and pans.)

,000.00

5000750000

,000.00

5001350003

,000.00

5001350006

,000.00

5001350009

,000.00

5001350000

,000.00

5001450000

,000.00

5001425000

28. Retail sales of home health care equipment and supplies (Include first aid products and surgical and medical
masks.)

,000.00

5001375000

29. Retail sales of pet foods and supplies

,000.00

5001250000

,000.00

5000925000

,000.00

5000950000

,000.00

5000975000

,000.00

5001725000

,000.00

5001750000

,000.00

5001950000

,000.00

5001930000

a. Retail sales of household soaps, detergents, and cleaners

b. Retail sales of household cleaning supplies, including mops, sponges, brooms, and brushes

Subtotal

25. Retail sales of prescription and nonprescription medicines, vitamins, minerals, and supplements

a. Retail sales of prescriptions

b. Retail sales of nonprescription medicines

c. Retail sales of vitamins, minerals, and other dietary supplements

Subtotal
26. Retail sales of cosmetics and fragrances (Include face cream, makeup, cologne, and perfume.)
(Report hair care products and nail polish on line 27.)
27. Retail sales of personal hygiene supplies (Include hand and foot care products, eye/contact lens care products, oral
hygiene products, deodorants, hair care products, nail polish, toilet paper, facial tissues, sanitary napkins, and
disposable diapers.)

30. Retail sales of books (Include audio books and e-books.)

31. Retail sales of magazines and newspapers, including issue format comic books

32. Retail sales of other publications, including greeting cards and calendars

33. Retail sales of automotive fuels

34. Retail sales of household fuels, including oil, LP gas, wood, coal

35. Retail sales of automotive parts and supplies

36. Retail sales of hardware, nonpower hand tools, and other building materials and supplies

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

37. Retail sales of home lawn and garden goods, excluding cut flowers and indoor potted plants

,000.00

5000805003

,000.00

5000805006

c. Retail sales of all other lawn and garden supplies, including fencing, irrigation equipment, sprinklers, and garden
hoses

,000.00

5000805009

d. Retail sales of pools, pool chemicals, and pool supplies and accessories

,000.00

5000805012

,000.00

5000805015

,000.00

5000805000

,000.00

5000810003

,000.00

5000810006

,000.00

5000810009

,000.00

5000810012

,000.00

5000810000

,000.00

5000680003

,000.00

5000680006

,000.00

5000680009

,000.00

5000680000

,000.00

5000375000

41. Retail sales of men's clothing

,000.00

5000350000

42. Retail sales of men's and women's clothing accessories (Include hats, gloves, neckwear, rain accessories, etc.)
(Report costume jewelry on line 46.)

,000.00

5000450000

a. Retail sales of powered lawn and garden tools, equipment, and machinery and parts

b. Retail sales of outdoor grills

e. Retail sales of outdoor nursery stock, including trees, shrubs, bedding plants, bulbs, sod, seeds, etc.

Subtotal
38. Retail sales of cut flowers and indoor potted plants

a. Retail sales of cut flowers -- unarranged

b. Retail sales of cut flowers -- arranged

c. Retail sales of indoor potted plants -- blooming

d. Retail sales of indoor potted plants -- nonblooming

Subtotal
39. Retail sales of other home furnishings and accessories
a. Retail sales of decorative accessories and home furnishings (Include lamps, lampshades, decorative glassware,
vases, giftware, mirrors, pictures, picture frames, clocks, magazine racks, desk sets, closet and bathroom
accessories, etc.)

b. Retail sales of artificial/silk flowers, plants, and trees

c. Retail sales of seasonal decorations (except decorative plates, napkins, and cups)

Subtotal

40. Retail sales of women's clothing

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

,000.00

5000425000

44. Retail sales of footwear and footwear accessories

,000.00

5000475000

45. Retail sales of children's wear, including boys', girls', and infants' and toddlers' clothing and accessories, including
school uniforms

,000.00

5000400000

,000.00

5000455000

47. Retail sales of small household appliances, including mixers; blenders; can openers; toasters; coffee makers;
frypans; personal care appliances, such as hair dryers, curling irons, and shavers; tap water purifiers and filters; etc.

,000.00

5000725000

48. Retail sales of window treatments, including rods, poles, and fixtures

,000.00

5000625000

49. Retail sales of domestics and other textile home furnishings (except carpet and rugs) (Include furniture coverings,
towels, sheets, blankets, table linens and coverings, etc.)

,000.00

5000650000

,000.00

5000875000

,000.00

5001000000

,000.00

5001125000

,000.00

5000900000

,000.00

5001775000

,000.00

5001400000

,000.00

5001075000

,000.00

5001700000

,000.00

5001025000

,000.00

5001105000

,000.00

5000860003

,000.00

5000860006

,000.00

5000860009

43. Retail sales of costumes, vestments, and unisex clothing

46. Retail sales of costume and novelty jewelry

50. Retail sales of televisions, audio and video equipment

51. Retail sales of audio and video recordings, including purchased downloads (excluding audio books)

52. Retail sales of toys, games, and hobby and craft supplies

53. Retail sales of photographic equipment and supplies

54. Retail sales of fabrics, yarns, and other sewing materials and supplies

55. Retail sales of glasses and contact lenses

56. Retail sales of hunting, fishing, hiking, and camping equipment

57. Retail sales of exercise/fitness equipment

58. Retail sales of bicycles and other cycles, all types, except children's sidewalk bikes, and parts and accessories

59. Retail sales of other sporting goods and equipment, excluding sport vehicles
60. Retail sales of household goods, not elsewhere classified

a. Retail sales of nonautomotive batteries

b. Retail sales of religious goods (except books)

c. Retail sales of souvenirs and novelty items

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

d. Retail sales of baby goods, not elsewhere classified, including bottles, monitors, carriers, swings, collapsible
playpens, infant and booster car seats, etc.

,000.00

5000860012

e. Retail sales of gift cards

,000.00

5000860015

,000.00

5000860000

,000.00

5001935003

,000.00

5001935006

,000.00

5001935009

,000.00

5001935012

,000.00

5001935015

,000.00

5001935018

,000.00

5001935000

,000.00

7011125000

,000.00

7006575000

,000.00

7014545000

,000.00

7000950000

,000.00

7002325000

,000.00

7014775000

,000.00

7014800000

,000.00

7005543000

,000.00

7003915000

,000.00

9900000000

Subtotal
61. Retail sales of office and school supplies, packaging and packing materials and supplies, and other general industry
and miscellaneous materials and supplies

a. Retail sales of office, school, and packaging supplies

b. Retail sales of stationery products, including stationery, pads, looseleaf paper, and related products

c. Retail sales of office paper, including computer printer, copier, and fax paper

d. Retail sales of artists' materials and supplies

e. Retail sales of gift wrap, gift bags, and tissue paper

f. Retail sales of other general industry and miscellaneous materials and supplies

Subtotal

64. Photofinishing services

65. Rental of pre-recorded cassettes, tapes, discs, or video games

66. Amusement park and arcade services

67. Copying and reproduction services

68. Fax transmission services, except fax broadcasting services

69. Document payment services, such as money order and check cashing services (Exclude traveler's check services.)

70. Traveler's check services

TOTAL - Sum of lines should equal total Sales, Shipments, Receipts, or Revenue reported in Item 5

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Search for product/service not listed

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 25: Franchise

ITEM 25: FRANCHISE
A. Was this establishment operating under any trademark(s) or brand name(s) authorized by a franchisor in 2022?
Yes - franchisee-owned establishment
Yes - franchisor-owned establishment
No
B. If yes, what was the trademark(s) or brand name(s) operated under?
Describe

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 26: Business Cooperative

ITEM 26: BUSINESS COOPERATIVE
A cooperative is a business or organization owned by, controlled by, and operated for the benefit of members using its services. Members (also known as user-owners) can be individuals
or organizations, and benefit from the use of services, products, and/or earnings generated by the co-op. This includes purchasing co-ops, member/patron organizations, membercontrolled non-profits, consumer co-ops, marketing co-ops, worker co-ops, etc.

Is this establishment a cooperative?
Yes
No

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 28: Special Items - Floor Space

ITEM 28: SPECIAL ITEMS - FLOOR SPACE
Include:
Only the floor space used/controlled by this company.
All space occupied by this establishment on every floor of multi-story buildings.

1. What was the total under-roof selling space?
(Enter the square footage of in-store selling space at the end of 2022. Include all store areas open to customers, including aisles,
elevators, etc. Exclude display windows fronting onto streets or walks, outdoor entrance ways, or other outdoor space.)

2. What was the total under-roof floor space?
(Enter the total square footage of all under-roof selling space plus all other space available at the end of 2022. Include dry storage,
refrigerated space, offices, workrooms, display windows, and enclosed entrance ways. Exclude outdoor space, even if covered.)

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Square feet as of
December 31,
2022

Item 28: Special Items - Self-Checkout

ITEM 28: SPECIAL ITEMS - SELF-CHECKOUT
Did this establishment offer a way for customers to self-checkout, with no or minimal assistance, in 2022?
Yes
No

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 28: Special Items - Ordering and Delivery Services

ITEM 28: SPECIAL ITEMS - ORDERING AND DELIVERY SERVICES
1. Did this establishment offer ordering by website, app, phone, or other means in 2022?
Yes
No
2. Did this establishment offer delivery services by its employees in 2022?
Exclude:
Third-party delivery services
Yes
No

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 28: Special Items - Exported Services

ITEM 28: SPECIAL ITEMS - EXPORTED SERVICES
Did this establishment sell services (not goods) to foreign businesses in 2022 (i.e., exported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).

Include:
Services provided to any foreign businesses, whether unaffiliated or affiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Exported goods
Services provided to domestic subsidiaries of foreign businesses
Yes
No

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 28: Special Items - Imported Services

ITEM 28: SPECIAL ITEMS - IMPORTED SERVICES
Did this establishment purchase services (not goods) from foreign businesses in 2022 (i.e., imported services)?
Foreign businesses are those located outside the United States (i.e., outside the 50 States, District of Columbia, U.S. Commonwealth Territories, or U.S. possessions).

Include:
Services purchased from any foreign businesses, whether unaffiliated or affiliated (i.e., foreign parent firms, subsidiaries, branches, etc.)
Exclude:
Imported goods
Services purchased from domestic subsidiaries of foreign businesses
Yes
No

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 29: Business Technologies

ITEM 29: BUSINESS TECHNOLOGIES
1. Did this establishment use touchscreens/kiosks for customer interface in its own operations in 2022?
Touchscreens/kiosks for customer interface are computers with touchscreens that allow customers to receive information or perform tasks related to the business, such as registering
for a service or purchasing items.

Include:
Self-checkout, self-check-in, touchscreen ordering, etc.
Yes
No
Do not know
2. Did this establishment use additive manufacturing (e.g., 3D printing) in its own operations in 2022?
Additive manufacturing is the process of making three-dimensional, solid objects from a digital file.
Yes
No
Do not know
3. Did this establishment use radio-frequency identification (RFID) in its own operations in 2022?
Radio-frequency identification (RFID) is the use of passive or active radio-frequency identification chips to track inventory, products, or other objects.

Exclude:
Bar codes read with a scanner
Yes
No
Do not know
4. Did this establishment use industrial robots in its own operations in 2022?
Industrial robots are automatically controlled, reprogrammable, and multipurpose machines used in industrial automated operations. They may be mobile, incorporated into stand-alone
stations, or integrated into a production line.

Include:
Industrial robotic equipment that typically performs palletizing, pick and place, machine tending, machine handling, dispensing, welding, and packing/repacking
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), driverless forklifts, automated storage and retrieval systems, CNC machining equipment, and service
robots
Yes
No
Do not know
5. Did this establishment use service robots in its own operations in 2022?
Service robots perform tasks for humans for personal or professional use, not in an industrial or warehouse setting.

Include:
Medical, cleaning, delivery, construction/demolition, and field (such as mining, firefighting, and forestry) service robots
Exclude:
Automated guided vehicles (AGV), autonomous mobile robots (AMR), CNC machining equipment, and industrial robots

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Yes
No
Do not know
6. Did this establishment use automated guided vehicles (AGV) or autonomous mobile robots (AMR) in its own operations in 2022?
Automated guided vehicles (AGV) are computer-controlled vehicles that use sensor-based systems and software to navigate fixed routes (including driverless forklifts).

Autonomous mobile robots (AMR) are computer-controlled vehicles that use sensor-based systems and software to navigate without the need for fixed routes.
Yes
No
Do not know

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 29: Business Technologies - Touchscreens/Kiosks for Customer Interface

ITEM 29: BUSINESS TECHNOLOGIES - TOUCHSCREENS/KIOSKS FOR CUSTOMER INTERFACE
How did this establishment acquire the touchscreens/kiosks for customer interface used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 29: Business Technologies - Additive Manufacturing

ITEM 29: BUSINESS TECHNOLOGIES - ADDITIVE MANUFACTURING
How did this establishment acquire the additive manufacturing (e.g., 3D printing) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 29: Business Technologies - Radio-Frequency Identification (RFID)

ITEM 29: BUSINESS TECHNOLOGIES - RADIO-FREQUENCY IDENTIFICATION (RFID)
How did this establishment acquire the radio-frequency identification (RFID) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 29: Business Technologies - Industrial Robots

ITEM 29: BUSINESS TECHNOLOGIES - INDUSTRIAL ROBOTS
How did this establishment acquire the industrial robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 29: Business Technologies - Service Robots

ITEM 29: BUSINESS TECHNOLOGIES - SERVICE ROBOTS
How did this establishment acquire the service robots used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 29: Business Technologies - Automated Guided Vehicles (AGV) or Autonomous Mobile Robots (AMR)

ITEM 29: BUSINESS TECHNOLOGIES - AUTOMATED GUIDED VEHICLES (AGV) OR AUTONOMOUS MOBILE ROBOTS (AMR)
How did this establishment acquire the automated guided vehicles (AGV) or autonomous mobile robots (AMR) used in its own operations?
Select ALL that apply.

Purchased
Leased/rented
Developed in-house
Other
Describe

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

Item 31: Remarks

ITEM 31: REMARKS
Please use this space for any explanations that may be essential in understanding your reported data. (Maximum length is 1,000 characters.)

You have

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

1000

characters remaining

Item 32: Establishment Information

ITEM 32: ESTABLISHMENT INFORMATION

Name

Secondary Name

Store/Plant

Number and Street

City, town, village, etc.

ZIP Code

State
Select State or Territory

99999-9999

Describe kind of business at this location

For employees that worked at more than one location, report the employment and payroll data for those employees at the ONE location where they spent most of their
working time.

2022
What was the number of employees for pay period including March 12?
2022
$

What was the annual payroll?

,000.00

2022
$

What was the first quarter payroll (January - March 2022)?

,000.00

2022
$

What were the sales, shipments, receipts, or revenue?

2022_RT-44511_su.pdf Generated 2022-12-15 16:06:20

,000.00

File Type	application/pdf
File Modified	2023-02-14
File Created	2022-12-15