ETA 9105 Employer Data Form

National Dislocated Workers Emergency Grant Application and Reporting Procedures

Employer Data Form ETA 9105_FINAL 9.5.19

Workforce Innovation and Opportunity Act: National Emergency Grant (NEG) Assistance-Application and Reporting Procedures

OMB: 1205-0439

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U.S. Department of Labor OMB Control No. 1205-0439

Employment and Training Administration Expiration Date: XX/XX/XXXX




Employer Data Form ETA 9105

National Dislocated Worker Grant Electronic Application System


Company/Industry

Location of Facility

Notification Type

Date of Notification

Layoff Date(s)

Number of Affected Workers






Closure:



Dates(s) of Rapid Response Actions

Number of Workers Contacted

Field Surveys Completed

TAA Petition

Number of Planned Participants

Labor Organization Representation


Contact with Employer:


Contact with Workers:





Date Filed:


Number of Workers Covered:


Not Applicable:




Type of Business:


Two-Digit NAIC Code:




























Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control number. Respondents’ obligation to complete this form is required to obtain or retain benefits (PL: 113-128 sec170). Public reporting burden for this collection of information is estimated to average 30 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. This is public information and there is no expectation of confidentiality. Send comments regarding this burden estimate to the U.S. Department of Labor, Office of National Response, Room C-5311, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0439).


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