OMB control number
Eligibility Questionnaire for HAVANA Act Payments
OMB 1405-0250 · STATE/AFA.
OMB 1405-0250
Implements the HAVANA Act of 2021, in which 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.
The latest form for Eligibility Questionnaire for HAVANA Act Payments expires 2026-04-30 and can be found here.
Latest Forms, Documents, and Supporting Material
Document Name |
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Form and Instruction |
Form and Instruction |
Supplementary Document |
Justification for No Material/Nonsubstantive Change |
Justification for No Material/Nonsubstantive Change |
Supplementary Document |
Supplementary Document |
Supporting Statement A |
Form DS-4316 Eligibility Questionnaire For HAVANA Act Payments
03. Legal Authorities - 30 Day HAVANA Act PRA.docx
ds4316 Aug 2022.pdf
Eligibility Questionnaire For HAVANA Act Payments All Historical Document Collections
| Revision of a currently approved collection | 2026-01-15 | ||
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Approved without change |
No material or nonsubstantive change to a currently approved collection | 2026-01-07 | |
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Approved |
RCF Recertification | 2026-01-07 | |
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Approved |
RCF Recertification | 2026-01-07 | |
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Withdrawn |
RCF New | 2024-06-10 | |
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Approved without change |
RCF New | 2023-06-21 | |
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Approved without change |
RCF New | 2023-04-13 | |
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Approved without change |
No material or nonsubstantive change to a currently approved collection | 2023-03-22 | |
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Approved without change |
Revision of a currently approved collection | 2022-11-21 | |
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Approved without change |
No material or nonsubstantive change to a currently approved collection | 2022-08-08 | |
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Approved with change |
New collection (Request for a new OMB Control Number) | 2022-04-25 |