Information Collection

States/Territories Reporting to the Federal Government IC (ETA 9169)

IC 221306 under ICR 202012-1205-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Instructions - WIOA Wage Conversion Chart - 123020.xlsx	Instruction
Instructions - WIOA Wage Conversion Chart - 123020.xlsx	Instruction
Effectiveness in Serving Employers Specs - 123020.docx	Instruction
Effectiveness in Serving Employers Specs - 123020.docx	Instruction
ETA-9169 WIOA Statewide and Local Performance Report Template ETA_9169 10.15.20.xlsx	Form
ETA 9169 WIOA Statewide and Local Performance Report Template ETA_9169 4.14.21.xlsx	Form

IC Title:

States/Territories Reporting to the Federal Government IC (ETA 9169)

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
Instruction			Instructions - WIOA Wage Conversion Chart - 123020.xlsx	Yes	No	Printable Only
Instruction			Effectiveness in Serving Employers Specs - 123020.docx	Yes	No	Printable Only
Form	ETA 9169	WIOA Statewide and Local Performance Report Template	ETA_9169 4.14.21.xlsx	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 249

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	249	-2	251
Annual IC Time Burden (Hours)	1,110	-8	1,118
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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