OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death

ICR 201306-1240-006 · 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
dol-govt-1.doc Supplementary Document Uploaded 2013-06-18 Repair queued
Section 8191.doc Supplementary Document Uploaded 2013-06-18 Repair queued
eCFR — Code of Federal Regulations.mht Supplementary Document Uploaded 2013-06-18 Repair queued
BLS Salary Data.doc Supplementary Document Uploaded 2013-06-18 Repair queued
2013 OPM Salary Table-Cleveland.pdf Supplementary Document Uploaded 2013-06-18 Available
SS for 1240-0022 (CA-721 and 722) 2013.doc Supporting Statement A Uploaded 2013-10-21 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 201306-1240-006
Historical Active 201004-1240-011
DOL/OWCP
Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death
Revision of a currently approved collection   No
Regular
Approved without change 12/27/2013
Retrieve Notice of Action (NOA) 10/30/2013
  Inventory as of this Action Requested Previously Approved
12/31/2016 36 Months From Approved 12/31/2013
10 0 13
14 0 17
5 0 6
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
  78 FR 40513 07/05/2013
78 FR 64979 10/30/2013
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 10 13 0 0 -3 0
Annual Time Burden (Hours) 14 17 0 0 -3 0
Annual Cost Burden (Dollars) 5 6 0 0 -1 0
No
No
The previous approved number of annual respondents (13), is now 10, which represents a decrease of 3. The previously approved number for burden hours was 17, and the requested number now is 14, a decrease of 3. The annual cost burden decreased from $6.00 (previous reporting) to $5.00, which is an adjustment of $1.00. As a result of the Department of Treasury now requiring all federal benefits payments to be made electronically, the CA-721 and CA-722 were revised to include space for claimants/beneficiaries to complete information related to direct deposit. The instructions to these forms were also revised regarding this requirement. Also, rather than requesting signature of the claimant, the CA-722 was revised to request signature of the person filing the claim. Additionally, both forms were revised to include an accommodation statement to inform claimants who have mental or physical limitations to contact DFEC if further assistance is needed with the claims process.
$142
No
No
No
No
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.
10/30/2013