Eligibility Questionnaire for HAVANA Act Payments

Forms and Documents

Document Name	Status
Form DS-4316 Eligibility Questionnaire For HAVANA Act Payments Form and Instruction	New
Signed Emergency Justification Letter 4-21.pdf Supplementary Document	2022-04-25
Legal Authorities -HAVANA Act PRA.docx Supplementary Document	2022-04-25
PRA Emergency -- Supporting Statement -- HAVANA Act 04-21.docx Supporting Statement A	2022-04-25

IC Document Collections

IC ID	Document Title	Status
253057	Eligibility Questionnaire For HAVANA Act Payments Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202204-1405-006
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Eligibility Questionnaire for HAVANA Act Payments
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 04/30/2022
Date Submitted to OIRA: 04/25/2022

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	100	0
Time Burden (Hours)	50	0
Cost Burden (Dollars)	0	0

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Abstract: Implements the HAVANA Act of 2021, in which Congress authorized federal agencies to make payments to affected current employees, former employees, and their dependents (hereinafter, “claimants” or “patients”) for qualifying injuries to the brain.

Emergency Justfication: The Department of State requests Office of Management and Budget (OMB) Emergency processing, pursuant to 5 C.F.R. 1320.13, of the DS-4316, Eligibility Questionnaire for HAVANA Act Payments. On October 8,2021, the President signed the "Helping American Victims affected by Neurological Attacks" (HAVANA) Act of 2021(Public Law 11746). In this statute, Congress authorized federal government agencies to make payment to affected current employees, former employees, and their dependents for qualifying injuries to the brain. This law requires the Department {and other agencies} to "prescribe regulations" implementing the HAVANA Act not later than I80 days after the effective date of the Act.

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Authorizing Statute(s): US Code: 22 USC 2651a Name of Law: Organization of Department of State
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Eligibility Questionnaire For HAVANA Act Payments	DS-4316	Eligibility Questionnaire for HAVANA Act Payments

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	100	0	0	100	0	0
Annual Time Burden (Hours)	50	0	0	50	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: See Supporting Statement.

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Annual Cost to Federal Government: $41,088

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/25/2022

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