Document
60-Day Notice of Proposed Information Collection: Eligibility Questionnaire for HAVANA Act Payments
The Department of State is seeking Office of Management and Budget (OMB) approval for the information collection described below. In accordance with the Paperwork Reduction Act ...
SUPPLEMENTARY INFORMATION:
Title of Information Collection:
Eligibility Questionnaire for HAVANA Act Payments
OMB Control Number:
1405-0250
Type of Request:
Extension of a Currently Approved Collection
Originating Office:
PERT, Office of Employee Relations, Employee Benefits and Assistance Division, Employee Assistance Branch (PERT/ER/EBA/EA)
Form Number:
DS-4316
Respondents:
Department of State employees, former employees, and their dependents, and the qualified physicians whom they have consulted.
Estimated Number of Respondents:
30
Estimated Number of Responses:
30
Average Time per Response:
30 minutes
Total Estimated Burden Time:
15 hours
Frequency:
On occasion
Obligation to Respond:
Required to Obtain or Retain a Benefit
We are soliciting public comments to permit the Department to:
- Evaluate whether the proposed information collection is necessary for the proper functions of the Department.
- Evaluate the accuracy of our estimate of the time and cost burden for this proposed collection, including the validity of the methodology and assumptions used.
- Enhance the quality, utility, and clarity of the information to be collected.
- Minimize the reporting burden on those who are to respond, including the use of automated collection techniques or other forms of information technology.
Please note that comments submitted in response to this Notice are public record. Before including any detailed personal information, you should be aware that your comments as submitted, including your personal information, will be available for public review.
Abstract of Proposed Collection
On October 8, 2021, the “Helping American Victims Affected by Neurological Attacks” (HAVANA) Act of 2021 (Pub. L. 117-46) was signed into law. In this statute, Congress authorized federal agencies to make payments to affected current employees, former employees, and their dependents for qualifying injuries to the brain. The DS-4316 provides the required medical substantiation for claims filed pursuant to the HAVANA Act and the Department's rule (22 CFR part 135).
Methodology
An individual wishing to make a claim under the HAVANA Act IFR will fill out the “Patient Demographics” portion of the DS-4316, and provide it to a U.S. board certified physician as defined in the Department rules. The physician will complete the form after examining the individual and reviewing their records and will fax or email the completed form to the Department.
Andrew Flashberg,
Acting Employee Relations Office Director, Bureau of Personnel and Training, U.S. Department of State.