Form 10-0132 Locality Pay system for Nurses and Other Health Care Per

OMB Approval Number: 2900-0519
Estimated burden: 45 minutes

LOCALITY PAY SYSTEM FOR NURSES AND OTHER HEALTH CARE PERSONNEL
DATA COLLECTION AND INSTRUCTIONS
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. Your participation is voluntary. We may not conduct or sponsor,
and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who must complete this form will average 45 minutes. This includes the time it will take to read instructions,
gather the necessary facts and fill out the form. The purpose of this data collection is to assure that VA nurses are paid an equitable salary.
SECTION I - GENERAL INFORMATION
1a. NAME OF ESTABLISHMENT

1b. ADDRESS (Number and Street)

3. CONTACT PERSON

4a. PHONE

5. DATE OF CONTACT

2. COUNTY/TOWN/INDEPENDENT CITY

4b. TITLE

6. SURVEY OCCUPATION OR SPECIALTY

7. TOTAL EMPLOYMENT
FTEE

8. SALARY INCREASES
Month increases
are normally effective:

Occupation or Specialty FTEE
9. NUMBER OF HOURS IN NORMAL WORKWEEK
OF OCCUPATION OR SPECIALTY SURVEYED:

Effective Date
of Last Increase:

Percent:

SECTION II - SALARY DATA
SURVEY JOB (GRADE/LEVEL)

ESTABLISHED JOB (TITLE/GRADE)

RATE OF PAY

TYPE

SECTION III - BONUS PAY
Description of Bonus Program and Amount Paid:

SECTION IV - PREMIUM PAY FOR THE OCCUPATION OR SPECIALTY BEING SURVEYED
1. Establishment's current overtime Rate:

2. Establishment's current shift
differential:

3. List Establishments differential for:

Daily
Weekly
PM
Night
4. Does your establishment provide for stand-by/on-call premium pay? (Check one)
pay practices and method of calculating payments:

Saturday
YES

Sunday
NO

Holiday

If yes, please provide description of premium

REMARKS (Attach salary table and establishment job descriptions, or prepare summary job description - continue on blank sheet if necessary)

SECTION V - DATA COLLECTOR(S)
SIGNATURE AND TITLE

VA FORM
MAR 2002

10-0132

DATE

SIGNATURE AND TITLE

DATE

INSTRUCTIONS FOR DATA COLLECTORS
SECTION I - GENERAL INFORMATION
1. Establishment name and address: Enter establishment name and address. Include zip
code.
2. County/township/independent city: Enter the county/township/independent city where
the establishment is located.
3. Name and Title of Person Interviewed: Enter the name and title of the establishment
official(s) who furnished the data.
4. Phone: Enter the phone number of the person interviewed. Include extension.
5. Date of Contact: Actual date that establishment was contacted for this survey.
6. Survey Occupation or Specialty: Enter occupation or specialty being surveyed.
7. Establishment employment: Enter total number of full-time equivalent employees (FTEE)
in the establishment. For the occupation or specialty being surveyed, enter the total FTEE employed
by the establishment in that occupation.
8. Month General Increases Normally Effective: Enter the month that general increases are
normally effected for this occupation or specialty at the establishment. If increases are given more
than once a year, indicate the most recent month of adjustment and explain other increases under
remarks.
Salary Increase Information: Enter information on effective date and percent of increases
granted within the last 12 months and any increases that are expected within the next year.
9. Number Hours in Normal Workweek for the Surveyed Occupation or Specialty: Enter
number of hours in the normal workweek. Note under remarks any scheduling practices such as
Baylor Plan (registered nurses) or compressed workweek.

SECTION II - SALARY DATA
Enter the title and grade of the survey job and the title and grade of establishment's job. Also
enter the salaries paid by the establishment for an employee whose experience and education is
comparable to the survey job description and indicate what type of data is being reported (e.g.,
minimum beginning rate, maximum rate in a range, average, mid-point, etc.).

SECTION III - BONUS PAY
Document the following information: Description of the plan and how bonus payments are
determined; amount of bonus paid; and when bonuses are paid.

SECTION IV - PREMIUM PAY FOR THE OCCUPATION BEING SURVEYED
Enter requested information to be used to authorize additional pay under Title 38 United States
Code (U.S.C.) 7453(j) and MP-5, part II, chapter 3.

SECTION V - REMARKS
Additional information or further explanation that may be necessary for preceding items.

VA FORM
MAR 2002

10-0132

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