Draft; 240; 1

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html


This form is for use with Non-Occupational Employment and Wage Statistics (Non-OEWS) 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 on the Office of Foreign Labor Certification website at https://www.dol.gov/agencies/eta/foreign-labor.  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 condition is met.


A.  Employer Point-of-Contact Information 

1.  Contact’s last (family) name *                                
2.  First (given) name *                                
3.  Middle name(s) §

4.  Telephone number *                                                                                    
5.  Extension §    
  
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






    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: *

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 No   
No
8a.The median wage is § 
$	                                      .	       
 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. Is based on wage data from how many workers? * (Minimum of 30 workers)
 
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. *
Yes No
11.  Does the survey include wages from workers in the occupation regardless of immigration status? *
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*


For public burden statement information, please see the Form ETA-9165 General Instructions.