Eligibility Questionnaire for HAVANA Act Payments

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-4316 Eligibility Questionnaire for HAVANA Act payments	Form	Modified	Available
Form DS-4316 Eligibility Questionnaire for Havana Act Payments	Form and Instruction	Modified	Available
Justification for NonSub Change 1405-0250.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2026-01-07	Available
Justification for Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-03-22	Available
ds4316 Aug 2022.pdf	Supplementary Document	Uploaded 2022-11-21	Available
Legal Authorities -30-day HAVANA Act PRA.docx	Supplementary Document	Uploaded 2022-11-21	Available
30-day Supporting Statement -- HAVANA Act 1405-0250.docx	Supporting Statement A	Uploaded 2022-11-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
253057	Eligibility Questionnaire For HAVANA Act Payments	Form	Modified	Eligibility Questionnaire for HAVANA Act payments
253057	Eligibility Questionnaire For HAVANA Act Payments	Form and Instruction	Modified	Eligibility Questionnaire for Havana Act Payments

ICR Details

OMB Control No: 1405-0250	ICR Reference No: 202601-1405-001
Status: Active	Previous ICR Reference No: 202303-1405-010
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Eligibility Questionnaire for HAVANA Act Payments
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/07/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/07/2026
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2026	01/31/2026	01/31/2026
Responses	100	0	100
Time Burden (Hours)	50	0	50
Cost Burden (Dollars)	0	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.

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Authorizing Statute(s): PL: Pub.L. 119 - 60 5604 Name of Law: NDAA FY 2026
   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
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 55456	09/09/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 70887	11/21/2022
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	100	0	0	0	0
Annual Time Burden (Hours)	50	50	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:

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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:  Yes

Description/Changes for Common Form Usage:  This request changes question 4 on the common form, from "January 1, 2016" to "September 11,2001", in compliance with the FY2026 NDAA.

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title
USDA/AgSEC	202601-0503-001CF	Eligibility Questionnaire for HAVANA Act Payments	Active	Eligibility Questionnaire For HAVANA Act Payments
DOJ/FBI	202601-1110-001CF	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS-FBI	Active	Eligibility Questionnaire For HAVANA Act Payments

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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: 01/07/2026

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