Eligibility Questionnaire for HAVANA Act payments

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U.S. Department of State

OMB Control No. 1405-0250
Expires xx-xx-20xx
Estimated Burden 60 Minutes

ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time required for searching
existing data sources, gathering the necessary data, providing the information and/or documents required, and reviewing the final collection. You do
not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this
burden estimate and/or recommendations for reducing it, please send them to: PRA Attorney, Office of the Legal Adviser/LM, Suite 4805, 2201 C
Street NW, Washington DC 20520.

Section I: Patient Demographics (Patient Only)
INSTRUCTIONS
This form is for Department of State employees, separated Department of State employees, Department retirees, and
dependents of such employees, separated employees, and retirees. Complete Section I and bring this form to your
board-certified physician along with any other medical records that may assist with determining a qualifying injury.
1. Last Name

2. First Name

3. Date of Birth (mm-dd-yyyy)

4. Email Address

5. Phone Number

6. Employer

7. Employment Status

8. Location of Incident

9. Date of Incident (estimated mm-yy, if unknown)

Section II: Qualifying Brain Injury Questionnaire (Physician Only)
INSTRUCTIONS
This section is only to be completed by a physician currently certified with the American Board of Psychiatry and
Neurology (ABPN), the American Board of Physical Medicine and Rehabilitation (ABPMR), the American Osteopathic
Board of Neurology and Psychiatry (AOBNP), or the American Osteopathic Board of Physical Medicine and
Rehabilitation (AOBPMR), who has a history of providing medical care for this patient. Please review the following
statements, any pertinent medical records, and provide your signature below. Once completed, fax this document only to
202-261-8186 or scan this document and send as an attachment to an email to: [email protected].
1.
Yes

No

Did the individual experience 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 Computer
Tomography scan (CT), or Magnetic Resonance Imaging scan (MRI), or Electroencephalogram (EEG)?

Yes

No

Did the individual receive a medical diagnosis of a Traumatic Brain Injury (TBI) that required active
medical treatment for 12 months or more?

Yes

No

Yes

No

Did the injury occur on or after September 11, 2001?

Yes

No

Do you have evidence or otherwise believe that the symptoms can be attributed to a pre-existing
condition?

2.

3.

Did the individual experience an 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?

4.

5.

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Section II: Qualifying Brain Injury Questionnaire (Physician Only) - Continued
6.
Yes

No

Does the individual require a full-time caregiver for activities of daily living, as defined by the Katz Index
of Independence of Daily Living?

The signature below attests that the certifying physician is currently certified with the ABPN, the ABPMR, the AOBNP, or
the AOBPMR, and solemnly affirms that it is their clinical opinion based on their knowledge, education, and belief that
the information above is correct.

Printed Name of Physician

Street Address, City, State and Zip Code

Signature of Physician

Date

Email Address

Phone Number

GENETIC INFORMATION NONDISCRIMINATION ACT (GINA) STATEMENT
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or
requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. For the provider completing
this form, do not provide any genetic information when responding to this request for medical information. Genetic Information, as defined by GINA,
includes the following: an individual's family medical history; the results of an individual's or family members' genetic tests; the fact that an individual or
an individual's family member sought or received genetic services; and genetic information of a fetus carried by an individual, or an individual's family
member, or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
PRIVACY ACT NOTICE
AUTHORITIES: The information sought is pursuant to the Further Consolidated Appropriations Act of 2020 and the HAVANA Act of 2021 (22 U.S.C.
2680b).
PURPOSE: The information solicited from this form will assist the Department of State in determining whether a board-certified neurologist has verified
a patient under their care has been reviewed for the appropriate medical eligibility criteria for potential payment under the HAVANA Act.
ROUTINE USES: The Department will not share this information externally. More information on the routine uses for the system can found in System
of Records Notice STATE-31, Human Resources Records.
DISCLOSURE: Providing the information requested on this form is voluntary; however, failure to provide such information may preclude eligibility for
payment authorized under the HAVANA Act of 2021.
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