View RCF - OIRA Conclusion

Title: Eligibility Questionnaire for Havana Act Payments

Type of RCF: RCF New

Description of Agency Usage: Federal covered employees and their covered dependents must use the form to submit for a one-time lump sum payment for an injury sustained as outlined in the HAVANA Act on or after January 1, 2016.

Authorizing Statute(s): None

Annual Cost to Federal Government:
Agency Contact: John Decato 202 720-1021

Common Form Information Collections (IC) in this RCF:

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Eligibility Questionnaire For HAVANA Act Payments		10	5	0	Form and Instruction	DS-4316	Eligibility Questionnaire for Havana Act Payments

RCF Summary of Burden:

	Total Request	Change Due to Agency Discretion
Annual Number of Responses	10	10
Annual Time Burden (Hours)	5	5
Annual Cost Burden (Dollars)	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: Changes from the previous RCF request