Information Collection

WIOA Annual State Performance Reporting

IC 221306 under ICR 201709-1205-001 · OMB 1205-0526.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0526 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA-9169 WIOA Annual State Performance Reporting	Form
Instructions - WIOA Wage Conversion Chart - 4.20.2016 FINAL.xlsx	Instruction
Effectiveness in Serving Employers Specs - 4.20.2016 FINAL.doc	Instruction
ETA-9169 WIOA Statewide and Local Performance Report Template ETA-9169_FINAL 12.4.17.xlsx	Form
ETA-9169_(changes) 12.4.17.xlsx Amended Joint Report_ETA-9169	IC Document

IC Title:

WIOA Annual State Performance Reporting

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 677

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ETA-9169	WIOA Statewide and Local Performance Report Template	ETA-9169_FINAL 12.4.17.xlsx	Yes	Yes	Fillable Fileable
Instruction			Effectiveness in Serving Employers Specs - 4.20.2016 FINAL.doc	Yes	No	Printable Only
Instruction			Instructions - WIOA Wage Conversion Chart - 4.20.2016 FINAL.xlsx	Yes	No	Printable Only

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 251

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	251	38	213
Annual IC Time Burden (Hours)	1,118	169	949
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Amended Joint Report_ETA-9169	ETA-9169_(changes) 12.4.17.xlsx	12/29/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.