Fillable Visiting-researcher-questionnaire-2014 Bureau of Labor Statistics Visting Researcher Questionnaire

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Visiting-researcher-questionnaire-2014 Bureau of Labor Statistics Visting Researcher Questionnaire

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OMB No. 1220-0180
Expires 12/31/2015
Bureau of Labor Statistics
Visiting Researcher Questionnaire
This questionnaire will assist the Bureau of Labor Statistics (BLS) in determining your eligibility to
access confidential microdata through the visiting researcher program 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.
1. Applicant Information
Name:
Title:
Email:
Phone:
Fax:
Mailing Address:
Affiliation with Institution:
Employee or faculty. If so, please specify: Full time Part time
Fellowship / Post-Doctoral Appointment. If so, please specify end date:
Other. Please specify:
Will you require access to the confidential information?
Yes
No
If yes, please provide a resume or CV.
2. Project Information
Title:
BLS Data
Set(s):
Non-BLS
Data Set(s):
Description of your approach to completing the project within a two-year time period. (For example, you
may plan to come to the BLS national office for three months to do your research all at once, or you may
plan to work periodically by coming once a month and researching a week at a time. Also, please detail
any special circumstances that may affect your availability to access data. Examples of special
circumstances include: grants, visiting professorships, fellowships, leaves of absence, and sabbaticals.)
How will you present your research?
Journal Articles(s)
Dissertation(s)
Conference(s)
Report for Government Agency
Other. Please specify:
3. Institution Information
Institution Legal Name:
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:
Title:
Email:
Phone:
Fax:
Mailing Address:
4. Sources of Funding
What are the sources of funding (if any) for this project?
5. Collaboration
Are you collaborating with any other universities or institutions for this project?
Yes
No
If yes
What university / institution?
Please list the names of the
collaborators.
Specify if any of those collaborators
need access to confidential microdata.
6. 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:
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 confidential information?
Yes
No
If yes, please provide their resume or CV.
2
7. Additional Individuals Seeking On-site Access to Confidential Microdata
Please specify any additional individuals who require access to confidential microdata. Attach a resume or
CV for each individual.
1.
Name:
Title:
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:
2.
Name:
Title:
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:
3.
Name:
Title:
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:
4.
Name:
Title:
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:
5.
Name:
Title:
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 confidential BLS data and for other
administrative purposes. Providing the information on this form is voluntary; however, the BLS will not
be able to grant access to confidential BLS data without this information. The BLS is authorized to
request the information on this form under Title 5, United States Code, Section 301.
3
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Completed 9 February 2020

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