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OMB Control No: 0690-0037	ICR Reference No: 202307-0690-001
Status: Historical Active	Previous ICR Reference No: 202302-0690-001
Agency/Subagency: DOC/OS	Agency Tracking No: Havana Act
Title: Eligibility Questionnaire for HAVANA Act Payments
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Emergency	Approval Requested By: 03/31/2023
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/17/2023
	Date Received in OIRA: 07/14/2023
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2023	10/31/2023	10/31/2023
Responses	20	0	20
Time Burden (Hours)	20	0	20
Cost Burden (Dollars)	0	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.

Emergency Justfication: 1. This collection is necessary without allowing for the time period normally associated with a routine submission for review under the provisions of the Paperwork Reduction Act. It is crucial that individuals experiencing qualifying injuries to the brain be examined and, if appropriate, submit their claims under the Act and receive payment for qualifying injuries as soon as possible. In addition, Congress mandated a deadline for these procedures be in place, which, although it has passed, indicated the urgency for providing payments; therefore, it is critical that the form be ready for the public to use as soon as the IFR is published. 2. This collection is essential to the mission of the Department of Commerce, which is committed to protecting its employees and their dependents from injury; and, to the extent possible, making a payment to them pursuant to the HAVANA Act for qualifying injuries to the brain incurred in connection with war, terrorist activity, or other incidents designated by the Secretary of State, and which were not the result of the willful misconduct of the covered individual. The purpose of this collection is to provide required documentation from a board-certified neurologist regarding the claimant's injuries.

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
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	CD-350, CD-350	,

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	20	20
Annual Time Burden (Hours)	20	20
Annual Cost Burden (Dollars)	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:

Annual Cost to Federal Government:

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: Calynn Jenkins 202 482-4491

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