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
Form DS-4316 Eligibility Questionnaire For HAVANA Act Payments Form and Instruction	Unchanged
03. Legal Authorities - 30 Day HAVANA Act PRA.docx Supplementary Document	2026-01-15
Justification for NonSub Change 1405-0250.docx Justification for No Material/Nonsubstantive Change	2026-01-07
Justification for Change.docx Justification for No Material/Nonsubstantive Change	2023-03-22
ds4316 Aug 2022.pdf Supplementary Document	2022-11-21
Legal Authorities -30-day HAVANA Act PRA.docx Supplementary Document	2022-11-21
02. Supporting Statement - 30 Day HAVANA Act PRA.docx Supporting Statement A	2026-01-15

IC Document Collections

IC ID	Document Title	Status
278757	Eligibility Questionnaire For HAVANA Act Payments Form and Instruction	New
253057	Eligibility Questionnaire For HAVANA Act Payments Form and Instruction	Unchanged

ICR Details

OMB Control No: 1405-0250	ICR Reference No: 202601-1405-007
Status: Received in OIRA	Previous ICR Reference No: 202601-1405-001
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Eligibility Questionnaire for HAVANA Act Payments
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular	Date Submitted to OIRA: 01/15/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2026
Responses	130	100
Time Burden (Hours)	65	50
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.

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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:
	90 FR 12786	08/19/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 12907	01/15/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

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

	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	130	100	0	-70	100	0
Annual Time Burden (Hours)	65	50	0	-35	50	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The Estimated Burden will change from 60 minutes to 30 minutes because the latter was considered to be a better estimate of the time burden for the respondents (the physicians).

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Annual Cost to Federal Government: $19,644

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:  The coverage date in question 4 of the DS-4316 was changed from “January 1, 2016” to “September 11, 2001”, pursuant to the National Defense Authorization Act, FY 2026 (signed into law on December 18, 2025). Reference to the Further Consolidated Appropriations Act of 2020 has been removed from the Privacy Act Notice on the DS-4316 Eligibility Questionnaire for HAVANA Act Payments. The Estimated Burden will change from 60 minutes to 30 minutes because the latter was considered to be a better estimate of the time burden for the respondents (the physicians).

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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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: 01/15/2026

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