Information Collection

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

IC 221306 under ICR 202411-1205-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Form 9169 Statewide Performance Report WIOA Statewide Performance Report Template and WIOA Local Performance Report Template IC (ETA-9169)	Form
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
Form 9169 Statewide Performance Report ETA_9169 CLEAN 12.10.24.xlsx	Form
Form 9169 Statewide Performance Report ETA_9169 CLEAN 2.6.2025.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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Form	Form 9169	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		02/09/2024

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

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