30-Day Notice of Proposed Information Collection: Eligibility Questionnaire for HAVANA Act Payments
The Department of State has submitted the information collection described below to the Office of Management and Budget (OMB) for approval. In accordance with the Paperwork Redu...
Notice of request for public comment and submission to OMB of proposed collection of information.
SUMMARY:
The Department of State has submitted the information collection described below to the Office of Management and Budget (OMB) for approval. In accordance with the Paperwork Reduction Act of 1995 we are requesting comments on this collection from all interested individuals and organizations. The purpose of this Notice is to allow 30 days for public comment.
DATES:
Submit comments up to February 17, 2026.
ADDRESSES:
Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to
www.reginfo.gov/public/do/PRAMain.
Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function.
FOR FURTHER INFORMATION CONTACT:
Direct requests for additional information regarding the collection listed in this notice, including requests for copies of the proposed collection instrument and supporting documents, to Carolina Linares, who may be reached on 771-205-0612 or at
ahicct@state.gov.
SUPPLEMENTARY INFORMATION:
Title of Information Collection:
Eligibility Questionnaire for HAVANA Act Payments.
OMB Control Number:
1405-0250.
Type of Request:
Renewal 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:
32.5 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 rules (22 CFR part 135). On December 18, 2025, section 5604 of the National Defense Authorization Act for FY 2026 changed the definition of qualifying injury to the brain to include such injuries occurring on or after September 11, 2001. The DS-4316 has been amended accordingly.
Methodology
An individual wishing to make a claim under the HAVANA Act 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 L. Flashberg,
Acting Employee Relations Office Director, Bureau of Personnel and Training, U.S. Department of State.