View Information Collection Request (ICR) Package
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View ICR - Agency Submission
COMMENT
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OMB Control No:
1405-0250
ICR Reference No:
202601-1405-007
Status:
Received in OIRA
Previous ICR Reference No:
202601-1405-001
Agency/Subagency:
STATE/AFA
Agency Tracking No:
Title:
Eligibility Questionnaire for HAVANA Act Payments
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
Yes
Type of Review Request:
Regular
Date Submitted to OIRA:
01/15/2026
Requested
Previously Approved
Expiration Date
36 Months From Approved
01/31/2026
Responses
130
100
Time Burden (Hours)
65
50
Cost Burden (Dollars)
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:
90 FR 12786
08/19/2025
30-day Notice:
Federal Register Citation:
Citation Date:
91 FR 12907
01/15/2026
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Eligibility Questionnaire For HAVANA Act Payments
DS-4316
Eligibility Questionnaire for HAVANA Act Payments
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 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
130
100
0
-70
100
0
Annual Time Burden (Hours)
65
50
0
-35
50
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:
Yes
Burden Reduction Due to:
Miscellaneous Actions
Short Statement:
The Estimated Burden will change from 60 minutes to 30 minutes because the latter was considered to be a better estimate of the time burden for the respondents (the physicians).
Annual Cost to Federal Government:
$19,644
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:
The coverage date in question 4 of the DS-4316 was changed from “January 1, 2016” to “September 11, 2001”, pursuant to the National Defense Authorization Act, FY 2026 (signed into law on December 18, 2025). Reference to the Further Consolidated Appropriations Act of 2020 has been removed from the Privacy Act Notice on the DS-4316 Eligibility Questionnaire for HAVANA Act Payments. The Estimated Burden will change from 60 minutes to 30 minutes because the latter was considered to be a better estimate of the time burden for the respondents (the physicians).
Approved RCFs using this ICR
Agency/Sub Agency
RCF ID
RCF Title
RCF Status
IC Title
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:
01/15/2026
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