Notice2026-00652
30-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
January 15, 2026
Issuing agencies
State Department
Abstract
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.
Full Text
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<title>Federal Register, Volume 91 Issue 10 (Thursday, January 15, 2026)</title>
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[Federal Register Volume 91, Number 10 (Thursday, January 15, 2026)]
[Notices]
[Page 1853]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2026-00652]
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DEPARTMENT OF STATE
[Public Notice 12907]
30-Day Notice of Proposed Information Collection: Eligibility
Questionnaire for HAVANA Act Payments
ACTION: Notice of request for public comment and submission to OMB of
proposed collection of information.
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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 <a href="http://www.reginfo.gov/public/do/PRAMain">www.reginfo.gov/public/do/PRAMain</a>. 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 <a href="/cdn-cgi/l/email-protection#701118191313043003041104155e171f06"><span class="__cf_email__" data-cfemail="ff9e97969c9c8bbf8c8b9e8b9ad1989089">[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: Renewal 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: 32.5 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 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.
[FR Doc. 2026-00652 Filed 1-14-26; 8:45 am]
BILLING CODE 4710-10-P
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This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.