2024-16792. Agency Information Collection Activities: Proposed Collection; Comment Request

Exhibit 1—Estimated Annualized Burden Hours

Form name	Number of respondents	Number of responses per POC	Hours per response	Total burden hours
1. Eligibility/Registration Form	85	1	3/60	5
2. Medical Office Site Information Form	85	30	5/60	213
3. Data Use Agreement	85	1	3/60	5
4. Data File(s) Submission	85	1	1	85
Total	NA	NA	NA	308

Exhibit 2—Estimated Annualized Cost Burden

Form name	Total burden hours	Average hourly wage rate *	Total cost burden
1. Eligibility/Registration Form	5	$ 64.58	$323
2. Medical Office Site Information Form	213	64.58	13,756
3. Data Use Agreement	5	64.58	323
4. Data File(s) Submission	85	64.58	5,489
Total	308	NA	19,891
* Mean hourly wage rate of $64.58 for Medical and Health Services Managers (SOC code 11-9111) was obtained from the May 2023 National Industry-Specific Occupational Employment and Wage Estimates, NAICS 621100—Offices of Physicians located at https://www.bls.gov/​oes/​current/​naics4_​621100.htm.