Eligibility Questionnaire for HAVANA Act Payments

Forms and Documents

Document Name	Status
Form CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS Form and Instruction	Unchanged
NSC Request Havana Act Eligibility Questionnaire 0690-0037.docx Justification for No Material/Nonsubstantive Change	2023-07-14
FINAL Dept of Commerce Havana Act - Emergency Justification Letter.pdf Supplementary Document	2023-03-24
FINAL 7.13.23 Supporting Statement -- DOC HAVANA Act.docx Supporting Statement A	2023-09-19

IC Document Collections

IC ID	Document Title	Status
259317	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS Form and Instruction	Unchanged

ICR Details

OMB Control No: 0690-0037	ICR Reference No: 202309-0690-002
Status: Received in OIRA	Previous ICR Reference No: 202307-0690-001
Agency/Subagency: DOC/OS	Agency Tracking No: Havana Act
Title: Eligibility Questionnaire for HAVANA Act Payments
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/19/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2023
Responses	20	20
Time Burden (Hours)	20	20
Cost Burden (Dollars)	0	0

---

Abstract: The Helping American Victims Affected by Neurological Attacks (HAVANA) Act of 2021 was signed by President Biden in October 2021. The Act provides for the possibility of one-time, lump sum payments for those affected by Anomalous Health Incidents (AHIs). This includes current and former Department employees, and dependents of current or former employees who, on or after January 1, 2016, became injured by a qualifying injury to the brain while they were an employee of the Department.

---

Authorizing Statute(s): PL: Pub.L. 117 - 46 2 Name of Law: HAVANA Act of 2021
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 38482	06/13/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 64409	09/19/2023
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	CD-350, CD-350	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS ,   ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS Fax Number Added

---

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	20	20	0	0	0	0
Annual Time Burden (Hours)	20	20	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $10,949

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

---

Common Form ICR:  No

---

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: 09/19/2023

---