CMS-29 Supporting Statement A. 03.16.21

Supporting Statement A

Verification of Clinic Data – Rural Health Clinic Program

Form CMS-29

A. Background

This is a request for extension of the OMB approval for the CMS-29 form, titled “Verification of Clinic Data – Rural Health Clinic Program” which is approved under OBM control number 0938-0074.

The form CMS-29 is utilized as an application to be completed by suppliers of Rural Health Clinic (RHC) services requesting participation in the Medicare program. This form initiates the process of obtaining a decision as to whether the conditions for certification are met by a supplier of RHC services. The CMS-29 form also promotes data input and retrieval from the Automated Survey Process Environment (ASPEN) and related survey and certification databases by the CMS Regional Offices (ROs). Should any question arise regarding the structure of the organization, this information is readily available.

Both new and existing clinics must provide and attest to the accuracy of specific clinic data as a part of the RHC certification process. Therefore, we are requesting to extend the existing approval.

B. Justification

1. Need and Legal Basis

Collection of this information is authorized by 42 CFR 491.1 through 491.12 pursuant to sections 1864 and 1875 of the Social Security Act. Organizations rendering RHC services may participate as Medicare suppliers. In order to determine compliance with the conditions for certification (CfC), the Secretary has authorized States through contracts to conduct surveys of health care suppliers. For Medicare purposes, certification is based on the State agency's recording and reporting to CMS of a supplier's compliance or noncompliance with health and safety requirements.

The Verification of Clinic Data – Rural Health Clinic Program, Form CMS-29, is a certification form provided by the State agency to those clinics seeking Medicare certification as a RHC. It is completed and returned by the applicant and evaluated subsequently through an on-site survey. The State agency has an inspector/surveyor review the facility's compliance with the RHC CfCs.

The verification form also details the clinic information that will be stored in the ASPEN and related survey and certification databases. The storage of the information allows for later retrieval for study reports and data collection.

2. Information Users

CMS uses the collected information to inform its certification and recertification decisions. When a clinic seeks certification in the Medicare program as a RHC, the State agency forwards the Verification of Clinic Data (CMS-29) to the clinic that will complete and returns the form. The information on the completed form serves as an initial screening tool for the State agency to determine if the clinic appears to satisfy basic certification requirements and is ready for a more detailed on-site compliance assessment.

3. Improved Information Technology

The basic identifying information from this form is incorporated into ASPEN and related survey and certification databases and serves as the information base for the creation of a record for future Federal recertification and analytical activity.\

However, the CMS-29 itself is in a non-fillable .pdf format that the RHC must download from the CMS website. The facility is required to fill in the following information on the CMS-29 form via handwriting or typewriter: (1) CCN number; (2) State/County; (3) State Region (4) full address and telephone number; (5)Name and address of clinic owners; (6) Medical Direction which included the type of clinic personnel; (7) type of control ( i.e. – individual, corporation, partnership or government); (8) indication as to whether the RHC is a provider-based entity to a hospital or critical access hospital (CAH); and if so, (9) state the CCN number of the hospital/CAH

The RHC is required to send the completed and signed original copy of the completed and signed CMS-29 form to the State Survey Agency (SA). Therefore, this form does not lend itself to electronic signature or electronic submission at this time. However, if, a later date, CMS considers converting this form to electronic submission, electronic signatures could be used.

4. Duplication of Similar Information

The CMS-29 does not duplicate any information collection. The form addresses unique regulatory CfCs that RHCs must meet to participate in the Medicare program. State agencies receive Federal funds for conducting these reviews under contract with CMS. This form is a basic deliverable under these contracts and is the only one of its kind collected by CMS for RHC suppliers.

5. Small Business

Some RHCs may be small businesses. The information collected is needed to assist in determining the RHC’s compliance with the CfCs. Collection of this information imposes a minimal burden and thus does not significantly affect small businesses.

The completion of the CMS-29 form is required when a RHC seeks participation in the Medicare program and also when the SA performs a survey of the RHC. These surveys are performed approximately once every 3 years therefore, the small business RHC’s will only be required to complete the CMS-29 form upon application for participation in the Medicare program and once every three years thereafter. If the information has not changes from the last CMS-29 form filed, the small business RHC could simply copy or scan the previous form and add an original signature, which would decrease the time burden associated with the completion of this form on a triennial basis.

6. Less Frequent Collection

This information is collected prior to the clinic’s initial certification, and subsequently once every six years on average, when the State agency conducts a recertification survey. Less frequent surveys and associated verification of the Form CMS-29 could reduce quality assurance protections to Medicare beneficiaries.

7. Special Circumstances for Information Collection

There are no special circumstances associated with this collection. These requirements comply with all general information collection guidelines in 5 CFR 1320.6.

8. Federal Register and Outside Consultation

The 60-day Federal Register notice published on March 19, 2021 (86 FR 14926). There were no comments.

The 30-day Federal Register notice published June 1, 2021 (86 FR 29264).

9. Payments or Gifts

There are no payments of gifts associated with this collection.

10. Confidentiality

We do not pledge confidentially

11. Sensitive Questions

There are no questions of a sensitive nature associated with this form.

12. Estimate of Burden

1. Time Burden Estimate:

As noted above, the completion of the CMS-29 form is required when a RHC seeks participation in the Medicare and every 3 year thereafter, when their recertification survey is performed. We estimate that there are an average of 290 new RHCs seeking participation in the Medicare program each year. We arrived at this figure by obtaining an average of the number of new RHCs over the past 5 years. Below are the number of new RHCs from 2016 to 2020.

Year	Number of New RHCs
2016	228
2017	245
2018	304
2019	298
2020	376
TOTAL	1,450
Average Number of New RHC’s Between 2016 and 2020	290

(1,450 divided by 5 years = 290 new RHCs per year)

In CY 2020, there were 4,791 RHCs enrolled in the Medicare Program. As RHCs are surveyed every 3 years, we estimate that approximately one-third of the existing RHCs would be surveyed per year. We estimate that 1,597 existing RHC providers would be surveyed per year.

• 4,791 RHC providers divided by 3 years = 1,597 RHC’s surveyed per year

1. Burden for completion of the “Initial” CMS-29 form when an RHC is applying for initial participation in the Medicare program.

New RHC that are seeking participation in the Medicare program will have to complete the CMS-29 form for the first time. For purposes of differentiation in the burden calculations we will refer to the CMS form completed by the new RHC providers as the “Initial CMS-29 form.”

We estimate that it would take a new RHC approximately 30 minutes to complete the initial CMS-29 form when the RHC is applying for participation in the Medicare Program.

As there are an average of 290 new RHC’s established each year, we estimate that it would take 145 hours across all new RHCs per year to complete the initial CMS-29 forms.

• 30 minutes per each CMS-29 form x 290 new RHCs per year = 8,700 minutes per all new RHCs per year

• 8,700 minutes divided by 60 minutes per hour = 145 hours/all new RHCs/year.

We believe that a Chief Executive Officer or comparable senior official authorized by the facility review and sign the CMS-29 form. According to the U.S. Bureau of Labor Statistics, average hourly salary of a Chief Executive Officer of $93.20^1. This wage, doubled for the employer’s overhead and fringe benefits, would be $186.40.

As it takes 30 minutes to prepare the “initial CMS-29 form” (i.e. – read, fill in the required information, sign and date), we estimate the cost burden associated with this task to be $93.18.

• $186.40 divided by 60 minutes per hour = $3.107 per minute

• $3.107 per minute x 30 minutes = $93.21

We further estimate that the total annual cost burden across all new RHCs for the completion of the “initial CMS-29 form” by the RHC’s CEO would be $27,028.

• $186.40 per hour x 145 hours = $27,028

2. Burden for completion of each “Survey” CMS-29 form by existing RHCs to be surveyed

RHC providers must complete the CMS-29 form each time they receive their triennial recertification survey. For purposes of identification in this burden estimate, we will refer to this form as the “Survey CMS-29 form.”

There are currently 4,791 RHCs in the U.S. As stated above, we estimate that approximately 1,597 existing RHCs would be surveyed by the SA each year and must complete the CMS-29 forms as part of this survey process.

We estimate that the time required for a RHCs being surveyed to complete the “Survey CMS-29 form” is approximately 20 minutes. As noted above we have estimated that it would take new RHC providers 30 minutes to complete the “Initial CMS-29 form”. However, we believe that it would take a new RHC provider more time to complete the CMS-29 form than it would for an existing RHC provider to do so for several reasons.

First, the existing RHCs would have previously filled out the CMS-29 form and should be familiar with the information required to complete said form. Second, the existing RHC providers would most likely have retained a copy of their previously completed CMS-29 form and could get the information required to complete the currently required CMS-29 form from it. In fact, if there is no change in the information to be filled in on the currently required CMS-29 form, the RHC could copy or scan the previous form and add an original signature and current date.

As noted above, we estimate that the time required for each existing RHC being surveyed to complete the “Survey CMS-29 form” is 20 minutes. We further estimate that the time required across all RHCs being surveyed per year to complete the “Survey CMS-29 form” is 532 hours

• 20 minutes per CMS-29 form x 1,597 RHCs being surveyed = 31,940 minutes per all RHCs being surveyed per year to complete the CMS-29 form

• 31,940 minutes per all RHCs being surveyed per year divided by 60 minutes per hour = 532 hours per all RHCs being surveyed per

We believe that a Chief Executive Officer or comparable senior official authorized by the facility would sign the CMS-29. According to the U.S. Bureau of Labor Statistics, the mean average hourly wage for a Chief Executive Officer of $93.20^2. This wage doubled for the employer’s overhead and fringe benefits would be $186.40.

We estimate the cost burden associated with preparation of each “survey CMS-29 form” by the RHC’s CEO would be $62.14.

• $186.40 divided by 60 minutes per hour = $3.107 per minute

• $3.107 per minute x 20 minutes = $62.14.

The total annual cost for the completion of all “survey CMS-29 forms” across all RHCs being surveyed would be $99,164.80.

• $186.40 per hour x 532 hours = $99,164.80.

3. Burden associated with review the statutory and regulatory law associated with CMS-29 form by new RHCs

We have added an additional time allowance to the burden estimate for new RHCs for the review of the applicable statutory and regulatory law associated with the CMS-29 form. It is important to note that we do not attribute such additional time burden for the existing RHC providers, as we believe the existing RHC staff should have already reviewed the applicable statutory and regulatory law when the initial CMS-29 form was completed.

We believe that a new RHC that is completing the CMS-29 form for the first time must become familiar with the statutory and CMS regulations associated with this form. Therefore, we have estimated that it would take approximately 25 minutes for each new RHC to review and become familiar with the statutory and CMS regulatory law associated with an RHC’s participation in the Medicare program.

We further estimate that it would take 121 hours of time across all new RHCs for this review:

• 25 minutes x 290 new RHCs = 7,250 minutes

• 7,250 minutes divided by 60 minutes per hour = 121 hours per all new RHCs

(Note: It is important to note that we have not assessed this time burden for the existing RHCs that have previously completed the CMS-29 form as we assume that they have already researched and become familiar with the applicable statutory and CMS regulatory law.)

We believe that a Chief Executive Officer or comparable senior official authorized by the facility would be expected to sign the CMS-29. According to the U.S. Bureau of Labor Statistics, average hourly salary of a Chief Executive Officer of $93.20^3. This wage, doubled for the employer’s overhead and fringe benefits, would be $186.40.

We estimate that the cost burden associated with this task per each new RHC would be $77.68.

• $186.40 divided by 60 minutes = $3.107

• $3.107 x 25 minutes = $77.68;

We further estimate that the total annual cost burden across all new RHCs for the review of the applicable regulatory and statutory law would be $22,554.40.

• $186.40 per hour x 121 hours = $22,554.40

4. Time required for photocopying of original copy of CMS-29 and filing of copy by a Medical Secretary (for both the initial and survey CMS-29 forms)

1. Initial CMS-29 Form

After the CEO has completed and signed the CMS-29, we estimate that it would next be given to a Medical Secretary for photocopying and filing of the photocopy. We estimate that this would take 5 minutes.

We estimate that the time required for the medical secretaries across all new RHCs to photocopy all “initial CMS-29 forms” would be 24 hours.

• 290 new RHCs per year x 5 minutes per new RHC per CMS-29 form = 1,450 minutes per all new RHCs per year

• 1,450 minutes per all new RHC’s per year divided by 60 minutes per hour = 24 hours per all new RHCs per year).

According to the U.S. Bureau of Labor Statistics, the mean hourly wage for a Medical Secretary is $18.31.⁴ This wage, adjusted for the employers overhead and fringe benefits is $36.62

We estimate that the cost for the photocopying and filing each “initial CMS-29 form” would be $3.05.

• $36.62 divided by 60 minutes per hour = $0.61

• $0.61 x 5 minutes = $3.05 per each RHC

We estimate that the cost for the photocopying and filing of all “initial CMS-29 forms” across all new RHCs would be $878.88.

• $36.62 x 24 hours per all new RHCs per year = $878.88

2. Survey CMS-29 Form”

We estimate that this would take 5 minutes for the medical secretary to photocopy the completed “Survey CMS-29 form.” We further estimate that the time required for the medical secretaries across existing RHCs being surveyed each year to photocopy all “survey CMS-29 forms” would be 133 hours.

• 1,597 RHCs being surveyed/year x 5 minutes per each CMS-29 form = 7,985 minutes per all RHCs being surveyed per year

• 7,985 minutes per all RHCs being surveyed per year divided by 60 minutes per hour = 133 hours per all RHCs being surveyed per year.

We estimate that the cost for the photocopying and filing each “survey CMS-29 form” would be $3.05.

• $36.62 divided by 60 minutes per hour = $0.61

• $0.61 x 5 minutes = $3.05 per each RHC

We further estimate that the cost for the photocopying and filing of all “survey CMS-29 forms” across all existing RHCs would be $4,870.46.

• $36.62 x 133 hours = $4,870.46

5. Time required for the preparation for and mailing of the CMS-29 form to the SA by a Medical Secretary (for both the initial and survey CMS-29 forms)

It is required that the RHC send the original copy of the CMS-29 form the SA by U.S. mail. Therefore, we estimate that after a photocopy of the original, completed and signed CMS-29 form has been made, a Medical Secretary will prepare the CMS-29 form for mailing (i.e., - preparing a mailing envelope addressed to the SA, putting the form into the envelope, sealing the envelope) and putting the envelope into the outgoing mail).

1. Initial CMS-29 Form

We believe that these activities will take approximately 10 minutes. We further estimate that the time required for all Medical Secretaries across all new RHCs to prepare the initial CMS-29 form for mailing would be 48 hours:

• 290 new RHCs per year x 10 minutes per new RHC per CMS-29 form = 2,900 minutes per all new RHCs per year

• 2,900 minutes per all new RHC’s per year divided by 60 minutes per hour = 48 hours per all new RHCs per year).

We estimate that the cost burden associated with the preparation for mailing of each completed “initial CMS-29 form” would be $6.10:

• $36.62 divided by 60 minutes per hour = $0.61

• $ 0.61 x 10 minutes = $6.10

The cost for the filing of the photocopy of all “initial CMS-29 form” across all new RHCs would be $1,757.76

• $36.62 x 48 hours = $1,757.76

2. Survey CMS-29 Form

As stated above, we believe that after completion of the CMS-29 by the CEO, a Medical Secretary will first photocopy the form, and file the copy in the appropriate location. We have accounted for the cost burden for these tasks on the section above.

After photocopying the completed “initial CMS-29 form” the Medical Secretary would them prepare the CMS-29 form for mailing, by preparing a cover letter and envelope, placing the original copy of the completed CMS-29 form in the envelope, sealing the envelope, affixing the proper amount of postage and putting the envelope into the outgoing mail.

We estimate that these tasks would take the Medical Secretary approximately 10 minutes to complete. We further estimate that the time required for all Medical Secretaries across all RHCs being surveyed to prepare the “survey CMS-29 form” would be 266 hours:

• 1,597 RHCs being surveyed x 10 minutes per each CMS-29 form = 15,970 minutes per all RHCs being surveyed per year

• 15,970 minutes per all RHCs being surveyed per year divided by 60 minutes per hour = 266 hours per all RHCs being surveyed per year).

We estimate that the total annual cost burden associated with the preparation for mailing of each completed “survey CMS-29 form” would be $6.10.

• $36.62 divided by 60 minutes per hour = $0.61

• $ 0.61 x 10 minutes = $6.10 per each RHC.

The cost for the preparation for mailing of all “survey CMS-29 form” across all existing RHCs would be $9,740.92

• $36.62 per hour x 266 hours existing RHCs surveyed per year = $9,740.92

6. Non-Labor Related Costs

Each new RHC that completes a CMS-29 must mail an original copy of the completed form to the State Survey Agency. This will require the facilities will incur costs for one first-class postage stamp or postage meter postage mark which would cost $0.55 per each initial or survey CMS-29 form mailed.

We estimate that the cost of postage across all RHCs filing an “initial CMS-29 form” would be $159.50.

• $0.55 x 290 = $159.50

We further estimate that the cost of postage across all RHCs filing a “survey CMS-29 form” would be $878.35

• $0.55 x 1,597 = $878.35

7. Summary of Time & Cost Burdens

Time burden the “Initial” CMS-29 Form per Each New RHC

Completion (i.e. – Review, fill in information, sign & date) by CEO: 20 minutes

Review of Statutory and CMS Regulatory law by CEO 25 minutes

Copying for form and filing of copy by Medical Secretary 5 minutes

Preparation for mailing and putting into mail by Medical Secretary 10 minutes

TOTAL TIME FOR PREPARATION OF INITIAL CMS-29 60 minutes

Time Burden for Initial” CMS-29 form across all new RHC’s

Preparation (i.e. – Review, fill in information, sign & date) by CEO: 145 hours

Review of Statutory and CMS Regulatory law by CEO 121 hours

Copying for form and filing of copy by Medical Secretary 24 hours

Preparation for mailing and putting into mail by Medical Secretary 48 hours

TOTAL TIME FOR PREPARATION OF INITIAL CMS-29 229 hours

Time burden for “Survey” CMS-29 Form per Each Existing RHC Being Surveyed

Completion (i.e. – Review, fill in information, sign & date) by CEO: 20 minutes

Copying for form and filing of copy by Medical Secretary 5 minutes

Preparation for mailing and putting into mail by Medical Secretary 10 minutes

TOTAL TIME FOR PREPARATION OF INITIAL CMS-29 35 minutes

Time burden for “Survey” CMS-29 Form across All RHCs Being Surveyed

Preparation (i.e. – Review, fill in information, sign & date) by CEO: 532 hours

Copying for form and filing of copy by Medical Secretary 133 hours

Preparation for mailing and putting into mail by Medical Secretary 266 hours

TOTAL TIME FOR PREPARATION OF INITIAL CMS-29 931 hours

Cost Burden for Each “Initial” CMS-29 Form”

Preparation (i.e. – Review, fill in information, sign & date) by CEO: $ 93.21

Review of Statutory and CMS Regulatory law by CEO: $ 77.68

Copying for form and filing of copy by Medical Secretary: $ 3.05

Preparation for mailing and putting into mail by Medical Secretary: $ 6.10

Non-Labor Related Costs: $ 0.55

TOTAL COST: $180.59

Cost Burden for All “Initial CMS-29 Forms” Across All New RHC’s

Preparation (i.e. – Review, fill in information, sign & date) by CEO: $27,028.00

Review of Relevant Statutory and Regulatory Law: $22,554.40

Copying for form and filing of copy by Medical Secretary: $ 878.88

Preparation for mailing and putting into mail by Medical Secretary: $ 1,757.76

Non-Labor Related Costs (Postage): $ 159.50

TOTAL COST $52,378.54

Cost Burden for EACH “Survey CMS-29 Form” Per Each Existing RHC Being Surveyed:

Preparation (i.e. – Review, fill in information, sign & date) by CEO: $62.14

Copying for form and filing of copy by Medical Secretary: $ 3.05

Preparation for mailing and putting into mail by Medical Secretary: $ 6.10

Non-Labor Related Costs (Postage): $ 0.55

TOTAL COST $71.84

Cost Burden for ALL “Survey CMS-29 Forms” Across All Existing RHC’s

Preparation (i.e. – Review, fill in information, sign & date) by CEO: $ 99,164.80

Copying for form and filing of copy by Medical Secretary: $ 4,870.46

Preparation for mailing and putting into mail by Medical Secretary: $ 9,740.92

Non-Labor Related Costs (Postage): $ 878.35

TOTAL COST $114,654.53

13. Capital Costs

There are no capital costs.

14. Cost to Federal Government

a. Cost for Processing of CMS-29 Forms by the State Survey Agency

Upon receipt of the completed and signed CMS-29 form, the State Survey Agency (SA) must process them and send them to the CMS Regional Office. We estimate that the SA staff would process approximately 1,887 CMS-29 forms per year, consisting of 290 initial CMS-29 forms from new RHCs and 1,597 survey CMS-29 forms from existing RHCs being surveyed (290 + 1,597 = 1,887).

We estimate that the SA staff would spend approximately 10 minutes per each form to process the forms. We further estimate that the SA staff would spend a total of 315 hours annually processing the CMS-29 forms.

1,887 CMS-29 forms annually x10 minutes = 18,870 minutes

18,870 minutes divided by 60 minutes per hour = 314.5 hours

We believe that the SA staff person that would process the CMS-29 forms would fall under the U.S. Bureau of Labor Statistics job category of Medical and Health Manager. The mean hourly wage for a Medical and Health Services Manager is $55.37⁵. This wage, adjusted for the employer’s overhead and fringe benefits, would be $110.74.

We estimate that the cost for processing per each CMS-29 form by the SA would be $18.50.

$110.74 divided by 60 minutes = $1.85

$1.85 x 10 minutes = $18.50

We further estimate that the total annual cost for the processing of all CMS-29 forms from all new RHCs and all RHCs being surveyed by the SA per year would be $34,883.10

$110.74 x 315 hours = $34,883.10

b. Cost for printing and distribution of the CMS-29 form.

We estimate that the cost to the Federal government for the printing and distribution of the CMS-29 forms would be $900.

c. Summary of Costs to the Federal Government

The total cost to the Federal government is $35,783.10.

$34,883.10 + $900 = $35,783.10

15. Burden Changes/Program changes

The table below shows the changes in burden from the previous PRA package.

	Total Burden Hours Requested	Total Burden Costs Requested	Due to Adjustment in OPDIV/ Office Estimate	Currently Approved
Total Number of Annual Responses	1,887 Responses		+263 Responses	1,624 Responses
Completion of all “Initial CMS-29 forms” across all new RHC’s.	145 hours	$27,028.00	+75 hours	70 hours
Review of statutory & regulatory law associated with all “Initial CMS-29 forms” by the facility CEO across all new RHC’s.	121 hours	$25,554.40	+33 hours	88 hours
Photocopying of all completed “Initial CMS-29 forms” by a medical secretary, across all new RHC’s	24 hours	$878.88	+6 hours	18 hours
Preparation for and Mailing of each “Initial” CMS-29 forms” by a medical secretary across all new RHC’s.	48 hour	$1,757.76	+13 hours	35 hours
Completion of all “Survey CMS-29 forms” across all existing RHC’s	532 hours	$99,164.80	+61 hours	236 hours
Copying & mailing of all “Survey CMS-29 forms” across all existing RHCs	133 hours	$4,870.46	+15 hours	118 hours
Burden for preparation for and mailing of all “Survey CMS-29 forms” by a medical secretary across all existing RHCs	266 hours	$9,740.92	+30 hours	236 hours
Total Hour Burden	1,269 hours		+468 hours	801 hours
Total Cost Burden		$170,033.07	+$38,348.67	$131,684.40

As noted in the above table, the total burden hours have increased by 468 hours and the total burden costs have increased by $38,348.67. We attribute this increase to several factors.

First, there has been an increase in the number of new RHCs and existing RHCs to be surveyed each year. In the previous PRA package it was estimated that there were 210 new RHCs per year and 1,414 RHCs surveyed per year. This equates to 1,624 responses per year.

In the current PRA package, we have estimated that there are 290 new RHCs per year and an average of 1,597 exiting RHCs to be surveyed each year. This equates to 1,887 responses per year. This would also be an increase in the number of responses in the amount of 263. When factored into the burden calculation, this increase in the number of responses results in an increase in the total burden hours and burden costs.

Second, we updated the wage information for the staff that performs the tasks associated with the completion of the CMS-29 form to the rates stated on the U.S. Bureau of Labor for 2019. For example, we updated the hourly wage rate for the medical secretary from $16.22 to $18.31. When factored into the burden calculations, this increased wage rate contributes to the increased cost burden.

16. Publication and Tabulation Dates

There are no publication and tabulation dates associated with this collection.

17. OMB Expiration Date

CMS will display the expiration date on the forms.

18. Certification Statement

There are no exceptions to the certification statement.

C. Collection of Information Employing Statistical Methods

There are no statistical methods employed in this information collection.

1 https://www.bls.gov/oes/current/oes111011.htm

2 https://www.bls.gov/oes/current/oes111011.htm

3 https://www.bls.gov/oes/current/oes111011.htm

4 https://www.bls.gov/oes/2019/may/oes436013.htm

5 https://www.bls.gov/oes/current/oes119111.htm

21