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 201004-1240-011 · 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 Available
SS for 1240-0022 (CA-721 and 722) 5-19-2010 FEEWCred071610[1].doc Supporting Statement A Uploaded 2010-07-23 Available
Production Workers, All Other.htm Supplementary Document Uploaded 2010-07-19 Repair queued
Salary Table 2010-CLE.htm Supplementary Document Uploaded 2010-07-19 Repair queued
Electronic Code of Federal Regulations.htm Supplementary Document Uploaded 2010-07-16 Repair queued
U_S_ Department of Labor - Office of Workers' Compensation Programs (OWCP) - Division of Federal Employees' Compensation (DFEC) -.htm Supplementary Document Uploaded 2010-07-16 Available
DOL GOVT-1[1].pdf Supplementary Document Uploaded 2010-07-16 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 201004-1240-011
Historical Active 201003-1240-022
DOL/OWCP
Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)
Revision of a currently approved collection   No
Regular
Approved without change 10/04/2010
Retrieve Notice of Action (NOA) 08/06/2010
  Inventory as of this Action Requested Previously Approved
10/31/2013 36 Months From Approved 10/31/2010
13 0 30
17 0 40
6 0 13
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
  75 FR 12272 03/05/2010
75 FR 47628 08/06/2010
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 13 30 0 0 -17 0
Annual Time Burden (Hours) 17 40 0 0 -23 0
Annual Cost Burden (Dollars) 6 13 0 0 -7 0
No
No
There is a decrease in 23 burden hours due to a reduction in the number of claims that have been filed which is an adjustment of minus 17. There has been a decrease in the operational and maintenance costs, from $13.20 ($13.00) to $6.00, for a decrease of $7.00, due to a reduction in the number of submitted claims.
$184
No
No
No
Uncollected
No
Uncollected
Marcus Sharpless 202 693-0998 [email protected]
  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.
08/06/2010