View Information Collection Request (ICR) Package
Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1405-0250
ICR Reference No:
202204-1405-006
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
STATE/AFA
Agency Tracking No:
Title:
Eligibility Questionnaire for HAVANA Act Payments
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Emergency
Approval Requested By:
04/30/2022
OIRA Conclusion Action:
Approved with change
Conclusion Date:
06/23/2022
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/25/2022
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
12/31/2022
6 Months From Approved
Responses
100
0
0
Time Burden (Hours)
50
0
0
Cost Burden (Dollars)
0
0
0
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.
Emergency Justfication:
The Department of State requests Office of Management and Budget (OMB) Emergency processing, pursuant to 5 C.F.R. 1320.13, of the DS-4316, Eligibility Questionnaire for HAVANA Act Payments. On October 8,2021, the President signed the "Helping American Victims affected by Neurological Attacks" (HAVANA) Act of 2021(Public Law 11746). In this statute, Congress authorized federal government agencies to make payment to affected current employees, former employees, and their dependents for qualifying injuries to the brain. This law requires the Department {and other agencies} to "prescribe regulations" implementing the HAVANA Act not later than I80 days after the effective date of the Act.
Authorizing Statute(s):
US Code:
22 USC 2651a
Name of Law: Organization of Department of State
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
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
DS-4316
Eligibility Questionnaire for HAVANA Act Payments
ICR Summary 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
0
0
100
0
0
Annual Time Burden (Hours)
50
0
0
50
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:
See Supporting Statement.
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
Agency Contact:
Alice Kottmyer 202 647-2318 kottmyeram@state.gov
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:
04/25/2022
An official website of the United States government
The .gov means it's official.
The site is secure.
