OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)

ICR 201003-1240-022 · OMB 1240-0022 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CA-721 Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722) Form and Instruction Modified Repair queued
Sections 10 .735 to 10.741 Non-Federal Law Enforcement Officers.doc Supplementary Document Uploaded 2007-01-11 Available
THE PRIVACY ACT OF 1974.doc Supplementary Document Uploaded 2007-01-11 Available
LAW 8191.doc Supplementary Document Uploaded 2007-01-11 Available
DOL GOVT-1.pdf Supplementary Document Uploaded 2007-01-11 Available
SS for 1215-0116 (CA-721 and 722) February 2007.doc Supporting Statement A Uploaded 2007-05-30 Available
IC Document Collections
IC IDCollectionTypeStatusForm
13785 Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722) Form and Instruction Modified
ICR Details
1240-0022 201003-1240-022
Historical Active 200406-1215-003
DOL/OWCP
Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)
Extension without change of a currently approved collection   No
Regular
Approved without change 03/12/2010
Retrieve Notice of Action (NOA) 03/12/2010
  Inventory as of this Action Requested Previously Approved
08/31/2010 36 Months From Approved
30 0 23
40 0 31
13 0 0
The CA-721 and CA-722 are used for filing claims for compensation for injury and death to non-Federal law enforcement officers under the provisions of 5 USC 8191 et seq. The forms provide the basic information needed to process the claims made for injury or death.
US Code: 5 USC 8191 Name of Law: The Federal Employee's Compensation Act
  
None
Not associated with rulemaking
  72 FR 9974 03/06/2007
72 FR 32866 06/14/2007
No
  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 30 23 0 0 7 0
Annual Time Burden (Hours) 40 31 0 0 9 0
Annual Cost Burden (Dollars) 13 0 0 0 13 0
No
No
There is an increase in the burden hours due to an increase in claims filed which is an adjustment of +9 burden hours. The increase in operation and maintenance is due to the increase in postage.
$367
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Carol Adams 904 357-4747 ext. 74105
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/14/2007