OMB control number
Eligibility Questionnaire for HAVANA Act Payments
OMB 0690-0037 ยท DOC/OS.
OMB 0690-0037
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.
The latest form for Eligibility Questionnaire for HAVANA Act Payments expires 2026-10-31 and is listed under ICR 202309-0690-002.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS | Form and Instruction |
 NSC Request Havana Act Eligibility Questionnaire 0690-0037.docx | Justification for No Material/Nonsubstantive Change |
| FINAL Dept of Commerce Havana Act - Emergency Justification Letter.pdf | Supplementary Document |
| FINAL 7.13.23 Supporting Statement -- DOC HAVANA Act.docx | Supporting Statement A |
 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202309-0690-002 | Extension without change of a currently approved collection | 2023-09-19 | Approved without change | |
| 202307-0690-001 | No material or nonsubstantive change to a currently approved collection | 2023-07-14 | Approved without change | |
| 202302-0690-001 | New collection (Request for a new OMB Control Number) | 2023-03-24 | Approved without change |