Information Collection

WIOA Statewide Performance Report Template and WIOA Local Performance Report Template IC (ETA-9169)

IC 221306 under ICR 202402-1205-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2.7.24 CLEAN.xlsx	Form
ETA 9169 WIOA Statewide and Local Performance Report Template ETA_9169 2.7.24 CLEAN.xlsx	Form
ETA_9169 2.7.24.xlsx WOIA Statewide and Local Performance Report - track changes	IC Document
ETA_9169 2.7.24.xlsx WOIA Statewide and Local Performance Report - track changes	IC Document

IC Title:

WIOA Statewide Performance Report Template and WIOA Local Performance Report Template 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 2.7.24 CLEAN.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	Previously Approved
Annual Number of Responses for this IC	249	249
Annual IC Time Burden (Hours)	1,110	1,110
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
WOIA Statewide and Local Performance Report - track changes	ETA_9169 2.7.24.xlsx	02/09/2024

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