Form ETA-9165 Employer-Provided Survey Attestations to Accompany H-2B

OMB Approval: 1205-0509
Expiration Date: XX/XX/XXXX

Employer-Provided Survey Attestations to Accompany H-2B Prevailing Wage
Determination Request Based on a Non-OES Survey
Form ETA-9165
U.S. Department of Labor

This form is for use with Non-Occupational Employment Statistics (Non-OES) surveys. Please read and review the Form ETA-9165 form instructions carefully before
completing this form and print legibly. A copy of the instructions can be found at http://www.foreignlaborcert.doleta.gov/. Those items marked with an asterisk (*) are
required and must be completed. Items marked with the section symbol (§) are conditional and are to be completed if the required if the condition is met.

A. Employer Point-of-Contact Information
1. Contact’s Last (family) Name *

2. First (given) Name *

4. Telephone Number *

5. Extension §

3. Middle Name(s) §
6. Fax Number §

7. E-Mail Address *

B. Employer Information
1. Legal business name *
2. Trade name/Doing Business As (DBA), if applicable §
3. Telephone number *

4. Extension §

5. Federal Employer Identification Number (FEIN from IRS) *

6. NAICS code (must be at least 4-digits) *

C. Employer-Provided Survey Information
1. Survey name or title *
2. Is there a collective bargaining agreement (CBA) applicable to the job opportunity? *



Yes



No

3. Are professional sports league’s rules or regulations applicable to the job opportunity? *



Yes



No

4. Is the surveyor an H-2B employer or the agent, representative, or attorney for any H-2B employer? *



Yes



No

7. Is the survey based on wages paid 24 months or less before the date of survey submission to ETA? *



Yes



No

8. Is this the most recent edition of the survey? (If this is the only edition, answer “yes”.) *



Yes



No

5. Enter the complete name of the third-party surveyor (individual or organization/association). *
6. Enter the name of the official representative of the third party surveyor who approved the survey. *
a. Contact’s Last (family) Name *

Form ETA-9165

b. First (given) Name *

FOR DEPARTMENT OF LABOR USE ONLY

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OMB Approval: 1205-0509
Expiration Date: XX/XX/XXXX

Employer-Provided Survey Attestations to Accompany H-2B Prevailing Wage
Determination Request Based on a Non-OES Survey
Form ETA-9165
U.S. Department of Labor

D.Relationship to job opportunity listed on the Form ETA-9141
1. Title(s) of the job(s) included in the survey *
2. Duties of the job(s) included in the survey (attach additional sheets as necessary) *

3. Identify the area of intended employment covered by the survey. *

(Please refer to the instructions for the definition of area of intended employment)

4. Was the survey expanded to include workers beyond the area of intended employment? *

 Yes

 No

4a. If yes to question 4, provide the geographic area surveyed §

4b. If yes to question 4, indicate the reason(s) the survey was expanded beyond the area of intended employment
(check all that apply) §

 to meet the 30 worker minimum. §
 to meet the 3 employer minimum. §
E. Survey Methodology
1. For the geographic area surveyed, provide the universe (number) of employers determined to employ workers in the
Occupation, including employers who were not surveyed. *
2. For the geographic area surveyed, provide the sources used to determine the universe (number) of employers who
employ workers in the occupation: *
3. For the geographic area surveyed, did the surveyor attempt to contact: ? * (Choose only one)
 All employers employing workers in occupation(s)

 A sample of employers in the geographic area

3a. If a sample, was the sample randomly selected? §

 Yes

 No

3b. If a sample, provide a brief summary of the procedures used to randomize the sample: §

4. The total number of employers from whom the surveyor attempted to solicit a survey response: *

Form ETA-9165

FOR DEPARTMENT OF LABOR USE ONLY

Page 2 of 3

OMB Approval: 1205-0509
Expiration Date: XX/XX/XXXX

Employer-Provided Survey Attestations to Accompany H-2B Prevailing Wage
Determination Request Based on a Non-OES Survey
Form ETA-9165
U.S. Department of Labor

5. For each responding employer, the survey includes the wages of all workers in the
occupation regardless of skill level or experience, education, and length of employment. *

 Yes

 No

6. The survey includes data collected across industries that employ workers in the occupation. *

 Yes

 No

7. The survey reflects the mean wage for all workers it covers. *

 Yes

 No

7a.The mean wage is §
$

7b. Per: (Choose only one) §

 Hour  Week  Month

.

8. The survey reflects the median wage for all workers it covers. *

 Yes

8a.The median wage is §
$

 No

8b. Per: (Choose only one) §

 Hour  Week  Month

.

9. The hourly, weekly, or monthly wage reported from the survey:
a. Is based on data provided by how many employers? *
(Minimum of 3 employers)

b. Reflects wages from workers within the occupation in the
geographic area surveyed? * (Minimum of 30 workers)
 Yes

 No

10. The hourly, weekly, or monthly wage rate reported by the survey includes all types of
wages paid to workers, including base rate of pay, commissions, cost-of-living allowance,
deadheading pay, guaranteed pay, hazard pay, incentive pay, longevity pay, piece rate,
portal-to-portal rate, production bonus, and tips. *
11. Does the survey include wages from workers in the occupation regardless of immigration
status? *

 Yes

 No

 Yes

 No

F. Employer Declaration
I declare under penalty of perjury that I have read and reviewed this application and that to the best of my knowledge the information contained
therein is true and accurate. I understand that to knowingly furnish materially false information in the preparation of this form and any supplement
thereto or to aid, abet, or counsel another to do so is a federal offense punishable by fines, imprisonment or both (18 U.S.C. 2, 1001, 1546, 1621).

1. Last (family) Name *

2. First (given) Name *

3. Middle Name(s) §

4. Title *
5. Signature*

6. Date Signed*

G. Public Burden Statement (1205-0509)
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The respondent’s
reply to these reporting requirements is required to obtain the benefits of temporary employment certification (Immigration and Nationality Act,
Section 101). Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate to the Office of Foreign Labor Certification ● U.S. Department of Labor ● Box 12200 ● 200 Constitution Ave., NW, ● Washington, DC 20210. Do NOT send the completed application to this address.

Form ETA-9165

FOR DEPARTMENT OF LABOR USE ONLY

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