OMB control number

Eligibility Questionnaire for HAVANA Act Payments

OMB 0690-0037 · DOC/OS.

OMB 0690-0037

The Helping American Victims Affected by Neurological Attacks (HAVANA) Act of 2021 was signed by President Biden in October 2021. The Act provides for the possibility of one-time, lump sum payments for those affected by Anomalous Health Incidents (AHIs). This includes current and former Department employees, and dependents of current or former employees who, on or after January 1, 2016, became injured by a qualifying injury to the brain while they were an employee of the Department.

The latest form for Eligibility Questionnaire for HAVANA Act Payments expires 2026-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS Form and Instruction
NSC Request Havana Act Eligibility Questionnaire 0690-0037.docx Justification for No Material/Nonsubstantive Change
FINAL Dept of Commerce Havana Act - Emergency Justification Letter.pdf Supplementary Document
FINAL 7.13.23 Supporting Statement -- DOC HAVANA Act.docx Supporting Statement A
ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS Form and Instruction

All Historical Document Collections

202309-0690-002 Approved without change	Extension without change of a currently approved collection	2023-09-19
202307-0690-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-07-14
202302-0690-001 Approved without change	New collection (Request for a new OMB Control Number)	2023-03-24