Notice2025-15801
60-Day Notice of Proposed Information Collection: Eligibility Questionnaire for HAVANA Act Payments
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
August 19, 2025
Issuing agencies
State Department
Abstract
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.
Full Text
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<title>Federal Register, Volume 90 Issue 158 (Tuesday, August 19, 2025)</title>
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[Federal Register Volume 90, Number 158 (Tuesday, August 19, 2025)]
[Notices]
[Page 40460]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2025-15801]
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DEPARTMENT OF STATE
[Public Notice: 12786]
60-Day Notice of Proposed Information Collection: Eligibility
Questionnaire for HAVANA Act Payments
ACTION: Notice of request for public comment.
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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
October 20, 2025.
ADDRESSES:
You may submit comments by any of the following methods:
<bullet> Web: Persons with access to the internet may comment on
this notice by going to <a href="http://www.Regulations.gov">www.Regulations.gov</a>. You can search for the
document by entering ``Docket Number: DOS-2025-0137'' in the Search
field. Then click the ``Comment Now'' button and complete the comment
form.
<bullet> Email: <a href="/cdn-cgi/l/email-protection#1e565f4e6c717d7b6d6d7770795e6d6a7f6a7b30797168"><span class="__cf_email__" data-cfemail="763e37260419151305051f181136050217021358111900">[email protected]</span></a>.
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 the Employee Assistance Branch, who may be
reached at <a href="/cdn-cgi/l/email-protection#f1b9b0a1839e92948282989f96b18285908594df969e87"><span class="__cf_email__" data-cfemail="b7fff6e7c5d8d4d2c4c4ded9d0f7c4c3d6c3d299d0d8c1">[email protected]</span></a>.
SUPPLEMENTARY INFORMATION:
<bullet> Title of Information Collection: Eligibility Questionnaire for
HAVANA Act Payments
<bullet> OMB Control Number: 1405-0250
<bullet> Type of Request: Extension of a Currently Approved Collection
<bullet> Originating Office: PERT, Office of Employee Relations,
Employee Benefits and Assistance Division, Employee Assistance Branch
(PERT/ER/EBA/EA)
<bullet> Form Number: DS-4316
<bullet> Respondents: Department of State employees, former employees,
and their dependents, and the qualified physicians whom they have
consulted.
<bullet> Estimated Number of Respondents: 30
<bullet> Estimated Number of Responses: 30
<bullet> Average Time per Response: 30 minutes
<bullet> Total Estimated Burden Time: 15 hours
<bullet> Frequency: On occasion
<bullet> Obligation to Respond: Required to Obtain or Retain a Benefit
We are soliciting public comments to permit the Department to:
<bullet> Evaluate whether the proposed information collection is
necessary for the proper functions of the Department.
<bullet> 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.
<bullet> Enhance the quality, utility, and clarity of the
information to be collected.
<bullet> 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.
[FR Doc. 2025-15801 Filed 8-18-25; 8:45 am]
BILLING CODE 4710-10-P
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