[Federal Register Volume 87, Number 174 (Friday, September 9, 2022)]
[Notices]
[Page 55456]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-19449]


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DEPARTMENT OF STATE

[Public Notice: 11853]


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 
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: [email protected].
    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 [email protected].

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.

Kevin E. Bryant,
Deputy Director, Office of Directives Management, U.S. Department of 
State.
[FR Doc. 2022-19449 Filed 9-8-22; 8:45 am]
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