# Agency Information Collection Activities; Submission for OMB Review; Comment Request; Eligibility Questionnaire for HAVANA Act Payments
The Department of Commerce will submit the following information collection request to the Office of Management and Budget (OMB) for review and clearance in accordance with the Paperwork Reduction Act of 1995, on or after the date of publication of this notice. We invite the general public and other Federal agencies to comment on proposed, and continuing information collections, which helps us assess the impact of our information collection requirements and minimize the public's reporting burden. Public comments were previously requested via the *Federal Register* on June 13, 2023, during a 60-day comment period. This notice allows for an additional 30 days for public comments.
*Agency:* Office of the Secretary, Department of Commerce.
*Title:* Eligibility Questionnaire for HAVANA Act Payments.
*OMB Control Number:* 0690-0037.
*Form Number(s):* CD-350.
*Type of Request:* Regular submission, extension of approved information collection.
*Number of Respondents:* 20.
*Average Hours per Response:* 1 hour (30 minutes claimant/30 minutes physician).
*Burden Hours:* 20.
*Needs and Uses:* An individual wishing to make a claim under the HAVANA Act IFR will fill out the “Patient Demographics” portion of the Eligibility Questionnaire (CD-350) and provide it to a physician currently certified with 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). The board-certified physician will complete the form after examining the individual and reviewing their records and will fax or email the completed form to the Department. The physician's findings will be instrumental in determining the individual's eligibility for payment under the HAVANA Act.
As noted in the IFR, the Department believes that many respondents to this information are already known to the Department due to prior reporting. Nevertheless, the Department notes that this form, which will be available on *www.commerce.gov/havana-act,* can be completed by any Department covered employee, covered individual, or covered dependent as a way of beginning an application for a HAVANA Act payment. Respondents to this information collection are individuals who believe they are eligible for payment under the HAVANA Act (Section I of the form) and physicians responsible for evaluating their symptoms and impairment (Section II of the form).
*Affected Public:* Individuals or Federal Government personnel.
*Frequency:* One-time payment.
*Respondent's Obligation:* Voluntary.
*Legal Authority:* HAVANA Act of 2021 (Pub. L. 117-46).
This information collection request may be viewed at *www.reginfo.gov.* Follow the instructions to view the Department of Commerce collections currently under review by OMB.
Written comments and recommendations for the proposed information collection should be submitted within 30 days of the publication of this notice on the following website *www.reginfo.gov/public/do/PRAMain.* Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function and entering either the title of the collection or the OMB Control Number 0690-0037.
Sheleen Dumas,
Department PRA Clearance Officer, Office of the Under Secretary of Economic Affairs, Commerce Department.