60-Day Notice of Proposed Information Collection: Eligibility Questionnaire for HAVANA Act Payments

ACTION:

Notice of request for public comment.

SUMMARY:

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 of 1995, we are requesting comments on this collection from all interested individuals and organizations. The purpose of this notice is to allow 60 days for public comment preceding submission of the collection to OMB.

DATES:

The Department will accept comments from the public up to November 8, 2022.

ADDRESSES:

You may submit comments by any of the following methods:

• Web: Persons with access to the internet may comment on this notice by going to www.Regulations.gov. You can search for the document by entering “Docket Number: DOS-2022-0030” in the Search field. Then click the “Comment Now” button and complete the comment form.

• Email: HIRTFStaffers@state.gov.

You must include the DS form number (if applicable), information collection title, and the OMB control number in any correspondence.

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 Susan Ware Harris, Senior Advisor, Health Incidents Response Task Force, who may be reached on 202-679-0127, or at HIRTFStaffers@state.gov.

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: S/HIRTF, Health Incidents Response Task Force.

• 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: 100.

• Estimated Number of Responses: 100.

• Average Time per Response: 30 minutes.

• Total Estimated Burden Time: 50 hours.

• Frequency: Once.

• 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, President Biden signed the “Helping American Victims Affected by Neurological Attacks” (HAVANA) Act of 2021 (Pub. L. 117-46). 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 recent rule, which was effective August 15,2022.

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 (currently certified by the American Board of Psychiatry and Neurology (ABPN) or the American Board of Physical Medicine and Rehabilitation (ABPMR)), who will complete the form after examining the individual and reviewing their records and will fax or email the completed form to the Department.