[Federal Register Volume 88, Number 16 (Wednesday, January 25, 2023)]
[Rules and Regulations]
[Pages 4722-4727]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2023-01410]


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DEPARTMENT OF STATE

22 CFR Part 135

[Public Notice: 11951]
RIN 1400-AF52


Implementation of HAVANA Act of 2021

AGENCY: Department of State.

ACTION: Final rule.

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SUMMARY: This rule finalizes the initial implementation by the 
Department of State (the Department) of the HAVANA Act of 2021. The Act 
provides authority for the Secretary of State and other

[[Page 4723]]

agency heads to provide payments to certain individuals who have 
incurred qualifying injuries to the brain. As noted in the interim 
final rule (IFR) published in June 2022, this rulemaking covers current 
and former Department of State employees, and dependents of current or 
former employees. This final rule responds to public comments and 
amends four provisions in the IFR, adding two additional certification 
Boards for physicians who can sign the Form DS-4316; clarifying the 
definition of ``qualifying injury to the brain;'' and adding approval 
for Social Security Insurance (SSI) benefits as one of the eligibility 
criteria for a Base Plus payment.

DATES: Effective date: This final rule is effective January 25, 2023.

FOR FURTHER INFORMATION CONTACT: Jenifer Moore, Advisor, Health 
Incident Response Task Force, email: [email protected], telephone 
number: 202-647-5010.

SUPPLEMENTARY INFORMATION: This rule implements the Helping American 
Victims Affected by Neurological Attacks (HAVANA) Act of 2021, Public 
Law 117-46, codified in 22 U.S.C. 2680b(i), which (among other things) 
required Department heads to publish implementing rules. The Department 
published an IFR on June 30, 2022 (87 FR 38981), which laid out the 
process for HAVANA Act claimants in a new 22 CFR part 135, and provided 
that physicians certified by the American Board of Psychiatry and 
Neurology (ABPN) could certify the Form DS-4316, Eligibility 
Questionnaire for HAVANA Act Payments. The IFR provided for 30 days of 
public comment. Based on some of the prevalent comments, the Department 
published a supplemental IFR on August 9, 2022 (87 FR 48444), which 
provided that physicians certified by the American Board of Physical 
Medicine and Rehabilitation (ABPMR) could certify the Form DS-4316. 
Both the IFR and supplemental IFR were effective August 15, 2022.
    Further background is contained in the preamble to the IFR.

Responses to Comments

    The Department received a total of 69 public comments in response 
to the IFR. Comments provided feedback under nine general categories: 
clinician criteria; date of injury restriction; imaging/magnetic 
resonance imaging scan (MRI) studies; ``other incident;'' length of 
qualifying medical treatment; payment eligibility criteria; qualifying 
injury definition; personal experience; and other. Many comments 
provided input on multiple subjects. Such comments were assigned to 
multiple categories. All comments are addressed in the aggregate below.
    1. Clinician criteria: Thirty comments challenged the clinician 
certification required to determine a qualifying injury to the brain. 
They stated that the requirement to be diagnosed by a board-certified 
neurologist from the American Board of Psychiatry and Neurology (ABPN) 
was too narrow, and that other certifications and physician specialties 
should be considered.
    As noted above, the Department accepted these comments and 
submitted a supplementary IFR to modify the provision of the IFR 
relating to the Board certification of the physician who is required to 
assess and diagnose an individual's qualifying injury to the brain and 
complete the Form DS-4316. In addition to the ABPN and the ABPMR, 
through this final rule, the Department provides that physicians 
currently certified by the American Osteopathic Board of Neurology and 
Psychiatry (AOBNP) and the American Osteopathic Board of Physical 
Medicine and Rehabilitation (AOBPMR) may certify the Form DS-4316. The 
regulatory text (Sec.  135.3) and the DS-4316 are being amended 
accordingly.
    2. Date of Injury Restriction: Fifteen comments focused on the date 
of injury, all expressing a belief that people who were affected by an 
anomalous health incident (AHI) earlier than January 1, 2016, should be 
eligible for a payment. The Department is unable to accept this 
suggestion. The HAVANA Act specifies that payments are for incidents 
occurring on or after January 1, 2016. The Department may not broaden 
the eligibility date without an amendment to the HAVANA Act or 
additional legislative action authorizing additional eligibility 
timeframes.
    3. Imaging/MRI Studies: Nine comments raised objections to what was 
perceived as a blanket requirement for imaging/MRI studies that 
supported a diagnosis of ``acute injury to the brain.'' This perception 
is not correct. An individual may submit an MRI or other imaging 
studies to the certified physician to demonstrate an acute injury to 
the brain, but that is not the only way to demonstrate a qualifying 
injury under the IFR. The IFR also permits individuals to submit 
electroencephalogram (EEG) results, physical examination results, or 
other appropriate testing results to their certified physician for use 
in their physician's assessment. The Department is adding an ``or'' 
between ``EEG'' and ``physical examination'' in the definition of 
``Qualifying injury to the brain'' (Sec.  135.2), between paragraphs 
(2)(i) and (ii), to clarify the language, and is also amending Question 
3 on the Form DS-4316 accordingly.
    4. ``Other Incident'': Seven comments noted that the language of 
the HAVANA Act regarding the occurrence of the injury (``in connection 
with war, insurgency, hostile act, or other incidents designated by the 
Secretary of State'') was very broad. With regard to ``other 
incidents'', the commenters stated that this language makes the 
determination subjective and not measurable, and asked how those who 
would be denied would know that the decision was made using objective 
criteria. One commenter expressed concern over who would determine that 
an ``attack'' had occurred.
    The definition of ``other incident'' in the IFR is: ``A new onset 
of physical manifestations that cannot otherwise be readily 
explained.'' For each request for payment, the Department will review 
available information on the reported incident, including any 
investigations that may have been conducted. If the reports and the 
results of investigations do not provide a credible alternate 
explanation for the incident, that incident will be recommended for 
designation by the Secretary of State or their designee. Incidents for 
which an explanation has been identified will not be recommended for 
designation.
    The list of reported incidents will be administratively controlled 
and will not be made public in order to ensure privacy for everyone who 
has reported an AHI. The IFR refers to only those from 2016 to the 
present because, as defined in the Act, only incidents that occurred on 
or after January 1, 2016, are eligible for payment. The Department 
maintains a list of all reported incidents; that list is not time-
limited.
    In the event of an adverse decision on a request for payment under 
the HAVANA Act, the Department has established an appeals process by 
which an individual may request further consideration.
    5. Length of Qualifying Medical Treatment: Nine comments provided 
feedback on the length of qualifying medical treatment criteria. All 
comments disagreed that 12 months of qualifying medical treatment 
should be a requirement, with several suggesting that the time period 
be shorter--for example, three months instead of 12 months. Some 
proposed that the 12 months of treatment be replaced with other 
criteria, citing examples such as, receiving prescription medication or 
therapy for brain injury-related conditions such as migraines, vertigo, 
vision problems, and hearing loss.

[[Page 4724]]

Another commenter suggested that the required 12 months of medical 
treatment be replaced with language that the ``demonstrated effect of 
injury'' was expected to last more than 12 months. The same comment 
expressed concern that covered employees who have been evaluated, but 
not yet had access to treatment, would not qualify otherwise and are 
excluded.
    Individuals may be eligible for a HAVANA Act payment if they meet 
one of three criteria under the definition of ``qualifying injury to 
the brain'': (1) an acute injury to the brain, such as, but not limited 
to, a concussion or penetrating injury, or as a consequence of an event 
that leads to permanent alterations in brain function as demonstrated 
by confirming correlative findings on imaging studies (to include 
computer tomography scan (CT) or MRI) or EEG; or (2) a medical 
diagnosis of a traumatic brain injury (TBI) that required active 
medical treatment for 12 months or more; or (3) acute onset of new 
persistent, debilitating neurologic symptoms as demonstrated by 
confirming correlative findings on imaging studies (to include CT or 
MRI), or EEG, or physical exam, or other appropriate testing and that 
required active medical treatment for 12 months or more.
    Of those three criteria, only (2) and (3) require 12 months of 
treatment, which would demonstrate that the individual suffers from a 
chronic condition.
    Even if a covered individual has not yet received 12-months or more 
of treatment as outlined in (2) or (3), the covered individual may 
nevertheless qualify at a later time if treatment lasts for twelve 
months or more. Such individuals are not excluded but will have to meet 
the criteria to be eligible for a payment.
    6. Payment eligibility criteria: Thirty-three comments discussed 
various aspects of the payment eligibility criteria. The majority of 
the comments expressed concern about who was eligible for payments. 
Another subset of comments questioned how eligibility is to be (or can 
be) determined without a clear definition or known cause of AHI. An 
additional comment raised a question about adequate funding for 
payments under the Act. The Department anticipates that resources will 
be available to provide payments to those who meet the eligibility 
criteria. One commenter asked what would happen if the Department 
underestimated the costs needed to pay all eligible requesters. The 
Department anticipates that resources will be available to provide 
payments to those who meet the eligibility criteria.
    Fourteen comments stated that the payment eligibility criteria 
should be expanded, challenged the scope of ``covered individuals'' 
defined in the Act, and specifically mentioned unpaid interns and 
Embassy Science Fellows as examples of persons who should be included. 
The Department agrees that the payment eligibility criteria should be 
expanded to include unpaid interns and will consequently insert 
``students providing volunteer services under 5 U.S.C. 3111'' after 
``Temporary Appointments'' in the definition of ``covered employee.'' 
The Department believes that Embassy Science Fellows are also covered 
under the definition of ``covered employee'', unless they are an 
employee of another Federal agency. In the latter case, the employing 
agency would be responsible for making a determination for payment and 
making a payment if qualified under that agency's rules. Additionally, 
the definition of covered employee has no reference to nationality, and 
employees who are citizens of other countries may qualify if they 
otherwise meet the criteria for payment.
    The State Department drafted the IFR in close coordination with the 
interagency and National Security Council. As contemplated by Congress, 
other Federal agencies will need to prepare their own rules for 
implementation of the HAVANA Act.
    Another comment questioned the objective capability of the 
Department to determine eligibility and award payment and suggested 
that a neutral outside board do so instead. The Department disagrees. 
For each request for payment, the Department will rely on the 
submission from the independent board-certified physician who completed 
the Form DS-4316, as well as available information on the reported 
incident, including any investigations that may have been conducted.
    One comment stated that bodily injuries caused by AHI should be 
eligible for payments under the Act. The Department notes that the 
HAVANA Act of 2021 specifically authorizes payments for qualifying 
``injuries to the brain,'' not ``bodily injuries''.
    Another comment shared a belief that the Department should make 
HAVANA Act payments posthumously to family members who had died because 
of mental health issues, arguing that not enough investigation has been 
done into the impacts of AHI on mental health illness. The Department 
notes that the HAVANA Act of 2021 specifically authorizes payments for 
qualifying ``injuries to the brain,'' not for mental health illnesses.
    Several comments pointed out that there was no definition for or 
known cause of AHI and asked how it would be possible to determine who 
would qualify under the HAVANA Act, which they viewed as too broad and 
susceptible to abuse. Conversely, multiple comments expressed concern 
that the medical requirements to show an injury to the brain were too 
stringent. In response, the Department notes that, recognizing that the 
nature of AHI includes a lack of consensus by the medical and 
scientific communities, the definition of ``qualifying injury to the 
brain'' in the IFR was written to be comprehensive, respect 
congressional intent, and allow the physician completing the Form DS-
4316 to consider appropriate medical information and context.
    Two comments proposed alternate/additional payment eligibility 
criteria under Sec.  135.3, Eligibility for payments by the Department 
of State, including allowing covered employees who have a Department-
approved reasonable accommodation to be eligible for a Base Plus HAVANA 
Act payment. One comment said that a medical retirement from the 
Department should be sufficient to qualify for a Base Plus HAVANA Act 
payment.
    In response to these two comments, the Department notes that it 
developed the eligibility criteria for a Base Plus payment under Sec.  
135.3 of the rule to cover individuals who have no employment potential 
with or without a reasonable accommodation. The Department believes 
that the four separate options for meeting the criteria in Sec.  
135.3(e)(2) represent a fair and consistent approach to determining 
Base Plus payments. In addition, the Department has added approval for 
Social Security Insurance (SSI) benefits as one of the eligibility 
criteria for a Base Plus payment.
    7. Qualifying Injury: The Department received 24 comments related 
to qualifying injury. Several comments noted that the IFR's definition 
of ``qualifying injury to the brain'' was not an actual definition, was 
too broad, and was open to ``vast'' interpretation. They asked if 
multiple sclerosis, idiopathic tics, dementia, epilepsy, Parkinson's, 
and several other medical conditions would qualify as an eligible 
injury. Other comments pointed out that traditional imagery is not 
likely to accurately identify changes to the brain, and that other 
documentation should be accepted or required, including vestibular 
tests. Likewise, some comments asserted a belief that TBI was a 
required diagnosis to qualify (which is inaccurate). Others expressed 
fraud and

[[Page 4725]]

abuse concerns as taxpayers on the potential monetary scope of payments 
under the Act. They stated their belief that AHIs were not real and 
noted that there is no International Classification of Diseases, Tenth 
Revision (ICD-10), diagnosis code for AHI. Therefore, there would be no 
way to ensure that prospective recipients had been affected by an AHI, 
as opposed to other causative factors.
    Recognizing that the nature of AHI includes a lack of consensus by 
the medical and scientific communities, the definition of ``qualifying 
injury to the brain'' in the IFR was written to be comprehensive, 
respect congressional intent, and allow the physician completing the 
Form DS-4316 to consider appropriate medical information and context. 
``Acute onset of new persistent, disabling neurologic symptoms as 
demonstrated by confirming correlative findings on imaging studies (to 
include CT or MRI), or EEG, or physical exam or other appropriate 
testing . . .'' recognizes that the board-certified physician who 
completes the Form DS-4316 may exercise their professional judgment as 
to what elements are relevant. An ICD-10 diagnosis code specifically 
for AHI is not necessary as payments are for qualifying injuries to the 
brain, which will have one or more relevant ICD-10 codes.
    Another comment specifically focused on children of affected 
covered employees, who reportedly did not receive evaluation of a 
possible AHI when their parent(s) were medically evacuated as the 
result of a suspected AHI. The comment states the writer's belief that 
dependents of AHI-affected employees should automatically qualify for a 
HAVANA Act payment without medical documentation, based on their 
parent(s)' injury. The Department notes that eligibility for a HAVANA 
Act payment under the IFR requires a currently board-certified 
physician to make a determination based in part on medical 
documentation submitted to the physician by the requester, and to 
complete the Form DS-4316 for each requester. Children of affected 
covered employees who may not have been evaluated at the time of the 
parent(s)' medevac may qualify for a payment if they meet the 
eligibility criteria.
    The Department also notes that imagery is one of several means by 
which requesters can establish eligibility for payment, and that the 
certifying physician will consider all available medical documentation 
when assessing the requester's condition. A diagnosis of a TBI is a 
non-exclusive criterion to potentially demonstrate eligibility under 
the HAVANA Act, and there are other ways in which an individual may 
meet the medical requirement, as listed in the definition. Regarding 
the concern that the injury may have been caused by factors other than 
an AHI, the physician must certify that they do not ``have evidence or 
otherwise believe that the [requester's] symptoms can be attributed to 
a pre-existing condition.''
    8. Personal Experience: Three comments shared detailed accounts of 
individual experiences. One comment expressed frustration that the 
Department of Defense has not implemented its policy or procedures 
regarding the HAVANA Act. Another comment shared the commenter's 
experiences related to clinician care for AHI. The third shared the 
commenter's AHI experience. The Department of State respects and 
recognizes the service of persons from numerous departments, agencies, 
and institutions, public and private, who are working or have worked to 
advance the interests of the United States. The Department's IFR only 
covers persons who were employed by the State Department and dependents 
of those persons when the reported AHI occurred. Other U.S. Federal 
Government agencies will need to complete their own rulemaking process 
to evaluate payment eligibility.
    9. Other: The Department received three comments that provided 
input on issues that are outside the scope of this rulemaking, 
including recommendations/comments on compensating employees for lost 
career growth as a result of an AHI; a belief that the Department must 
work with the Department of Labor (Federal Employees' Compensation Act 
(FECA)) on FECA requirements for TBI; and speculation about directed 
energy weapons. One commenter took the opportunity to address another 
comment with which they disagreed. The Department also received an 
email from an individual who felt that the Department's ``product'' was 
linking to their family's devices.
    The Department has a process to compensate employees for 
demonstrated lost career growth as a result of an AHI. It was given 
this authority under previous legislation. The Department also works 
closely with the Department of Labor on FECA claims filed by its 
employees, but the Department of Labor sets the requirements for 
eligibility for FECA benefits.

Regulatory Analysis

Administrative Procedure Act

    This rule is being published as a final rule. Because this rule is 
a matter relating to public benefits, it is exempt from the 
requirements of 5 U.S.C. 553. See 5 U.S.C. 553(a)(2). Since the rule is 
exempt from the entirety of section 553 pursuant to section 553(a)(2), 
the provisions of section 553(d) do not apply and the rule will be in 
effect upon publication.

Congressional Review Act

    The Office of Information and Regulatory Affairs (OIRA) in the 
Office of Management and Budget (OMB) has determined that this rule is 
not a major rule as defined by 5 U.S.C. 804 for the purposes of 
congressional review of agency rulemaking under the Small Business 
Regulatory Enforcement Fairness Act of 1996 (5 U.S.C. 801-808).

Unfunded Mandates Reform Act of 1995

    This rule will not result in the expenditure by State, local, or 
tribal governments, in the aggregate, or by the private sector, of $100 
million in any year; and it will not significantly or uniquely affect 
small governments. Therefore, no actions were deemed necessary under 
the provisions of the Unfunded Mandates Reform Act of 1995.

Executive Order 13175--Consultation and Coordination With Indian Tribal 
Governments

    The Department has determined that this rulemaking will not have 
tribal implications, will not impose substantial direct compliance 
costs on Indian tribal governments, and will not pre-empt tribal law. 
Accordingly, the requirements of Executive Order 13175 do not apply to 
this rulemaking.

Regulatory Flexibility Act: Small Business

    The Department of State certifies that this rulemaking will not 
have an impact on a substantial number of small entities. A regulatory 
flexibility analysis is not required under the Regulatory Flexibility 
Act (5 U.S.C. 601, et seq.).

Executive Order 12866 and Executive Order 13563

    The Department of State has provided this final rule to OMB for its 
review. OIRA has designated this rule as ``significant'' under 
Executive Order 12866. Potential causes of AHI are being investigated 
but remain unknown. Given the nature of the incidents, it is difficult 
to accurately estimate future incidents and numbers of individuals

[[Page 4726]]

affected. The Department approved/obligated funds for five cases 
totaling $796,025 by the expiration of Fiscal Year (FY) 2022 on 
September 30. This is below our previous FY 22 estimate of $1,545,225 
primarily because we did not begin accepting requests for payment until 
45 days before the end of the fiscal year. For FY 2023, the estimated 
numbers are up to $7.3 million for 47 people. The Department has also 
reviewed the rule to ensure its consistency with the regulatory 
philosophy and principles set forth in Executive Order 12866 and finds 
that the benefits of the rule (in providing mechanisms for individuals 
to obtain compensation for certain injuries) outweigh any costs to the 
public, which are minimal. The Department of State has also considered 
this rulemaking in light of Executive Order 13563 and affirms that this 
regulation is consistent with the guidance therein.

Executive Order 12988

    The Department of State has reviewed this rule in light of 
Executive Order 12988 to eliminate ambiguity, minimize litigation, 
establish clear legal standards, and reduce burden.

Executive Orders 12372 and 13132

    This rule will not have substantial direct effect on the states, on 
the relationships between the National Government and the states, or on 
the distribution of power and responsibilities among the various levels 
of government. Therefore, in accordance with Executive Order 13132, it 
is determined that this rule does not have sufficient federalism 
implications to require consultations or warrant the preparation of a 
federalism summary impact statement. Executive Order 12372, regarding 
intergovernmental consultation on Federal programs and activities, does 
not apply to this regulation.

Paperwork Reduction Act

    This rulemaking is related to an information collection for the 
Form DS-4316, ``Eligibility Questionnaire for HAVANA Act Patients,'' 
OMB Control Number 1405-0250. This collection was approved under an 
emergency authorization. After OIRA approved the changes, the DS-4316 
has been revised in accordance with the supplemental IFR and this final 
rule. The Department published a 60-day notice on September 9, 2022 (87 
FR 55456). No public comments were received. The Department published a 
30-day notice on November 21, 2022 (87 FR 70887) and OIRA approved the 
information collection on January 13, 2023.

List of Subjects in 22 CFR Part 135

    Federal retirees, Government employees, Health care.

    Accordingly, for the reasons stated in the preamble, the interim 
rules adding and amending 22 CFR part 135, which were published on June 
30, 2022 (87 FR 38981), and August 9, 2022 (87 FR 48444), are adopted 
as final with the following changes:

PART 135--IMPLEMENTATION OF THE HAVANA ACT OF 2021

0
1. The authority citation for part 135 continues to read as follows:

    Authority:  22 U.S.C. 2651a; 22 U.S.C. 2680b.


0
2. Amend Sec.  135.2 as follows:
0
a. By revising paragraph (2) of the definition of ``Covered employee'' 
and paragraph (2) of the definition of ``Qualifying injury to the 
brain''; and
0
b. By placing the definition of ``Other incident'' into alphabetical 
order.
    The revisions read as follows:


Sec.  135.2   Definitions.

* * * * *
    Covered employee. * * *
    (2) The following are considered employees of the Department (see 
procedures in 3 FAM 3660 and its subchapters) for the purposes of this 
part: Department of State Foreign Service Officers; Department of State 
Foreign Service Specialists; Department of State Civil Service 
employees; Consular Affairs--Appointment Eligible Family Member 
Adjudicator positions; Expanded Professional Associates Program 
members; Family Member Appointments; Foreign Service Family Reserve 
Corps; employees on Limited Non-Career Appointments; Temporary 
Appointments; students providing volunteer services under 5 U.S.C. 
3111; personnel on a Personal Services Contract; Locally Employed 
Staff, whether employed on a Personal Services Agreement, Personal 
Services Contract, or appointed to the position; and Embassy Science 
Fellows, unless they are an employee of another Federal agency.
* * * * *
    Qualifying injury to the brain. * * *
    (2) The individual must have:
    (i) An acute injury to the brain such as, but not limited to, a 
concussion, penetrating injury, or as the consequence of an event that 
leads to permanent alterations in brain function as demonstrated by 
confirming correlative findings on imaging studies (to include computed 
tomography scan (CT) or magnetic resonance imaging scan (MRI)) or 
electroencephalogram (EEG); or
    (ii) A medical diagnosis of a traumatic brain injury (TBI) that 
required active medical treatment for 12 months or more; or
    (iii) Acute onset of new persistent, disabling neurologic symptoms 
as demonstrated by confirming correlative findings on imaging studies 
(to include CT or MRI), or EEG, or physical exam, or other appropriate 
testing, and that required active medical treatment for 12 months or 
more.

0
3. Amend Sec.  135.3 by revising paragraphs (a) through (c) and (e)(2) 
to read as follows:


Sec.  135.3   Eligibility for payments by the Department of State.

    (a) The Department of State may provide a payment to covered 
individuals, as defined in this part, if the qualifying injury to the 
brain was assessed and diagnosed in person by a currently board-
certified physician from the American Board of Psychiatry and Neurology 
(ABPN), the American Osteopathic Board of Neurology and Psychiatry 
(AOBNP), the American Board of Physical Medicine and Rehabilitation 
(ABPMR), or the American Osteopathic Board of Physical Medicine and 
Rehabilitation (AOBPMR); occurred on or after January 1, 2016; and 
while the individual was a covered employee of the Department.
    (b) The Department of State may provide a payment to covered 
employees, as defined in this part, if the qualifying injury to the 
brain was assessed and diagnosed in person by a currently board-
certified physician from the ABPN, AOBNP, ABPMR, or AOBPMR; occurred on 
or after January 1, 2016; and while the employee was a covered employee 
of the Department.
    (c) The Department of State may provide a payment to a covered 
dependent, if the qualifying injury to the brain was assessed and 
diagnosed in person by a currently board-certified physician from the 
ABPN, AOBNP, ABPMR, or AOBPMR; occurred on or after January 1, 2016; 
and the dependent's sponsor was a covered employee of the Department at 
the time of the dependent's injury.
* * * * *
    (e) * * *
    (2) Whether the Department of Labor (Workers' Compensation) has 
determined that the requester has no reemployment potential; or the 
Social Security Administration has approved the requester for either 
Social Security Disability Insurance or Supplemental Security Insurance 
(SSI) benefits; or the requester's ABPN, AOBNP, ABPMR, or

[[Page 4727]]

AOBPMR board-certified physician has certified that the individual 
requires a full-time caregiver for activities of daily living, as 
defined by the Katz Index of Independence of Daily Living.
* * * * *

Kevin E. Bryant,
Deputy Director, Office of Directives Management, U.S. Department of 
State.
[FR Doc. 2023-01410 Filed 1-24-23; 8:45 am]
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