Eligibility Questionnaire for HAVANA Act Payments

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CD-350 CD-350 Form 508 Compliant	Form	New	Available
Form CD-350 CD-350 Final 508 Compliant Havana Act	Form	Modified	Available
Form CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	Form and Instruction	Modified	Available
Public Comments Submission by Mail Part 2_received April 7.2026.pdf	Public Comments	Uploaded 2026-10-30	Available
Public Comments Submission by Mail Part 1_received April 7.2026.pdf	Public Comments	Uploaded 2026-10-30	Available
NSC Request Havana Act Eligibility Questionnaire 0690-0037.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-07-14	Available
FINAL Dept of Commerce Havana Act - Emergency Justification Letter.pdf	Supplementary Document	Uploaded 2023-03-24	Available
Supporting Statement Part A Havana Act Renewal 2026.docx	Supporting Statement A	Uploaded 2026-10-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
283431	CD-350 Final Compliant Form 10 29 2026	Form	New	CD-350 Form 508 Compliant
259317	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	Form	Modified	CD-350 Final 508 Compliant Havana Act
259317	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	Form and Instruction	Modified	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS
259317	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	Instruction	Modified

ICR Details

OMB Control No: 0690-0037	ICR Reference No: 202610-0690-001
Status: Received in OIRA	Previous ICR Reference No: 202309-0690-002
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: 10/30/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	40	20
Time Burden (Hours)	40	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:
	91 FR 3416	01/27/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 68488	10/30/2026
Did the Agency receive public comments on this ICR? Yes

---

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

table that charts list of burden

IC Title	Form No.	Form Name
CD-350 Final Compliant Form 10 29 2026	CD-350	CD-350 Form 508 Compliant
ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	CD-350, CD-350	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS ,   CD-350 Final 508 Compliant Havana Act

---

ICR Summary of Burden

table that charts list 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	40	20	0	20	0	0
Annual Time Burden (Hours)	40	20	0	20	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: Respondent update due to renewal analysis from previous renewal submission

---

Annual Cost to Federal Government: $13,608

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: 10/30/2026

---