OMB Approval: 1205-0508
Expiration Date: XX/XX/XXXX
Employer-Provided Survey Attestations to Accompany H-2B Prevailing Wage
Determination Request Based on a Non-OEWS Survey
Form ETA-9165
U.S.
Department of Labor
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) § |
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4. Telephone number * |
5.
Extension §
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6. Fax number § |
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7. E-Mail address * |
B. Employer Information
1. Legal business name * |
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2. Trade name/Doing Business As (DBA), if applicable § |
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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
1. Survey name or title * |
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2. Is there a collective bargaining agreement (CBA) applicable to the job opportunity? * |
Yes No |
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3. Are professional sports league’s rules or regulations applicable to the job opportunity? * |
Yes No |
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4. Is the surveyor an H-2B employer or the agent, representative, or attorney for any H-2B employer? * |
Yes No |
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5. Enter the complete name of the third-party surveyor (individual or organization/association). *
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6. Enter the name of the official representative of the third-party surveyor who approved the survey. * |
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a. Contact’s last (family) name *
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b. First (given) name * |
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7. Is the survey based on wages paid 24 months or less before the date of survey submission to ETA? * |
Yes No |
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8. Is this the most recent edition of the survey? (If this is the only edition, answer “yes”.) * |
Yes No |
Relationship to job opportunity listed on the Form ETA-9141
1. Title(s) of the job(s) included in the survey * |
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2. Duties of the job(s) included in the survey (attach additional sheets as necessary) *
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3. Identify the area of intended employment covered by the survey. * (Please refer to the instructions for the definition of area of intended employment) |
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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 § |
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4b. If yes to question 4, indicate the reason(s) the survey was expanded beyond the area of intended employment (check all that apply) §
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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. * |
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2. For the geographic area surveyed, provide the sources used to determine the universe (number) of employers who employ workers in the occupation: * |
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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 |
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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: § |
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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 |
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6. The survey includes data collected across industries that employ workers in the occupation. * |
Yes No |
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7. The survey reflects the mean wage for all workers it covers. * |
Yes No |
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7a.The mean wage is § $ . |
7b. Per: (Choose only one) § Hour Week Month |
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8. The survey reflects the median wage for all workers it covers. * |
Yes No No |
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8a.The median wage is § $ . |
8b. Per: (Choose only one) § Hour Week Month |
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9. The hourly, weekly, or monthly wage reported from the survey: |
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a. Is based on data provided by how many employers? * (Minimum of 3 employers)
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b. Is based on wage data from how many workers? * (Minimum of 30 workers)
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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 |
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11. Does the survey include wages from workers in the occupation regardless of immigration status? * |
Yes No
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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 * |
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5. Signature* |
6. Date signed* |
For public burden statement information, please see the Form ETA-9165 General Instructions.
Form
ETA-9165 FOR DEPARTMENT OF
LABOR USE ONLY Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Miscellaneous; 240; 1 |
Author | Woods, Alexander T - ETA |
File Modified | 0000-00-00 |
File Created | 2022-09-09 |