View Information Collection Request (ICR) Package
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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:
202601-1405-001
Status:
Active
Previous ICR Reference No:
202303-1405-010
Agency/Subagency:
STATE/AFA
Agency Tracking No:
Title:
Eligibility Questionnaire for HAVANA Act Payments
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
Yes
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
01/07/2026
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/07/2026
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2026
01/31/2026
01/31/2026
Responses
100
0
100
Time Burden (Hours)
50
0
50
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.
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
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:
87 FR 55456
09/09/2022
30-day Notice:
Federal Register Citation:
Citation Date:
87 FR 70887
11/21/2022
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, DS-4316
Eligibility Questionnaire for Havana Act Payments
,
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
100
0
0
0
0
Annual Time Burden (Hours)
50
50
0
0
0
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:
No
Burden Reduction Due to:
Short 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:
Yes
Description/Changes for Common Form Usage:
This request changes question 4 on the common form, from "January 1, 2016" to "September 11,2001", in compliance with the FY2026 NDAA.
Approved RCFs using this ICR
Agency/Sub Agency
RCF ID
RCF Title
RCF Status
IC Title
DOJ/FBI
202601-1110-001CF
ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS-FBI
Active
Eligibility Questionnaire For HAVANA Act Payments
USDA/AgSEC
202601-0503-001CF
Eligibility Questionnaire for HAVANA Act Payments
Active
Eligibility Questionnaire For HAVANA Act Payments
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:
01/07/2026
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