View RCF  - OIRA Conclusion

202601-1110-001CF 202304-1110-001CF
Active 01/31/2026
DOJ/FBI
1405-0250 202601-1405-001
ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS-FBI
RCF Recertification
 Approved   01/07/2026
Retrieve Notice of Action (NOA) 01/07/2026
DOJ is authorized to make only minor changes to the host IC to make it usable for DOJ claimants. This includes changing agency seals, updating addresses, etc. Any substantive change that modifies the information being collected in any way falls outside of the common form approval and is prohibited.
On October 8, 2021, President Biden signed the “Helping American Victims Affected by Neurological Attacks” (HAVANA) Act of 2021 (Public Law 117-46). In this statute, Congress authorized federal agencies to make payments to affected current employees, former employees, and their dependents (hereinafter, “claimants” or “patients”) for qualifying injuries to the brain. This law requires the Department (and other agencies) to “prescribe regulations” implementing the HAVANA Act. The Department intends to publish an interim final rule (IFR), which will fulfill the mandate of the HAVANA Act. As described below, the Eligibility Questionnaire for Havana Act Payment form will provide the required medical substantiation for claims filed pursuant to the HAVANA Act and the Department’s rule.
PL: Pub.L. 117 - 46 1828 Name of Law: The Havana Act of 2021
 
Myaa Amoah 202 693-4566 [email protected]

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Eligibility Questionnaire For HAVANA Act Payments 25 13 0 Form and Instruction DS-4316 Eligibility Questionnaire for Havana Act Payments
Form DS-4316 Eligibility Questionnaire for HAVANA Act payments

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 25 25 0 0 0 0
Annual Time Burden (Hours) 13 13 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0

Yes
Changing Regulations
No