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U.S. Department of Labor

Bureau of Labor Statistics

Occupational Requirements 

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. Per the 

Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from 

malicious activities through cybersecurity screening of transmitted data.

This report is authorized 

by law, 29 U.S.C. 9. 

Your voluntary 

cooperation is needed to 

make the results of this

survey comprehensive, 

accurate and timely.

O.M.B. 

#1220-0189

Expires 

8/31/2018

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 (1220-0189), 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

Start Time/End Time:

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

ORS Form15-1P (revised 2017)
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 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
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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
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Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY - Leveling Schedule Number:

Quote: Occupation:

Establishment Grade: SOC:

Establishment Rate Range:

Non-supervisory Lead Supervisory 

Establishment Job Title:

Factor Level Education, experience, other comments

KNOWLEDGE

JOB CONTROLS AND 

COMPLEXITY

CONTACTS

PHYSICAL ENVIRONMENT

Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY - Leveling Schedule Number:

Quote: Occupation:

Establishment Grade: SOC:

Establishment Rate Range:

Non-supervisory Lead Supervisory

Establishment Job Title:

Factor Level Education, experience, other comments

KNOWLEDGE

JOB CONTROLS AND 

COMPLEXITY

CONTACTS

PHYSICAL ENVIRONMENT

Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY - Leveling Schedule Number:

Quote: Occupation:

Establishment Grade: SOC:

Establishment Rate Range:

Non-supervisory Lead Supervisory

Establishment Job Title:

Factor Level Education, experience, other comments

KNOWLEDGE

JOB CONTROLS AND 

COMPLEXITY

CONTACTS

PHYSICAL ENVIRONMENT

Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY - Leveling Schedule Number:

Quote: Occupation:

Establishment Grade: SOC:

Establishment Rate Range:

Non-supervisory Lead Supervisory

Establishment Job Title:

Factor Level Education, experience, other comments

KNOWLEDGE

JOB CONTROLS AND

COMPLEXITY

CONTACTS

PHYSICAL ENVIRONMENT

Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY - Leveling Schedule Number:

Quote: Occupation:

Establishment Grade: SOC:

Establishment Rate Range:

Non-supervisory Lead Supervisory

Establishment Job Title:

Factor Level Education, experience, other comments

KNOWLEDGE

JOB CONTROLS AND 

COMPLEXITY

CONTACTS

PHYSICAL ENVIRONMENT

Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY - Leveling Schedule Number:

Quote: Occupation:

Establishment Grade: SOC:

Establishment Rate Range:

Non-supervisory Lead Supervisory

Establishment Job Title:

Factor Level Education, experience, other comments

KNOWLEDGE

JOB CONTROLS AND 

COMPLEXITY

CONTACTS

PHYSICAL ENVIRONMENT

Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY - Leveling Schedule Number:

Quote: Occupation:

Establishment Grade: SOC:

Establishment Rate Range:

Non-supervisory Lead Supervisory

Establishment Job Title:

Factor Level Education, experience, other comments

KNOWLEDGE

JOB CONTROLS AND 

COMPLEXITY

CONTACTS

PHYSICAL ENVIRONMENT

Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY - Leveling Schedule Number:

Quote: Occupation:

Establishment Grade: SOC:

Establishment Rate Range:

Non-supervisory Lead Supervisory

Establishment Job Title:

Factor Level Education, experience, other comments

KNOWLEDGE

JOB CONTROLS AND

COMPLEXITY

CONTRACTS

PHYSICAL ENVIRONMENT

Remarks
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OCCUPATIONAL REQUIREMENTS SURVEY –

Base Leveling Supervisor

Schedule Number:

Supervisor

1st 2nd 3rd 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
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OCCUPATIONAL REQUIREMENTS SURVEY –

Leveling on Duties and Responsibilities of Supervisor

Schedule Number:

Supervisor

1st 2nd 3rd 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
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OCCUPATIONAL REQUIREMENTS 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
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OCCUPATIONAL REQUIREMENTS 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)
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Remarks