Information Collection

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

IC 13785 under ICR 201306-1240-006 · OMB 1240-0022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0022 can be found here:

Documents and Forms

Document Name Document Type
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
CA-721 Notice of Law Enforcement Officer's Injury or Occupation ca-721 revised.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-722 Notice of Law Enforcement Officer's Death ca-722 revised.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 10.735

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-721	Notice of Law Enforcement Officer's Injury or Occupational Disease	ca-721 revised.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	CA-722	Notice of Law Enforcement Officer's Death	ca-722 revised.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: DOL/GOVT-1	FR Citation: 67 FR 16826

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	-3	13
Annual IC Time Burden (Hours)	14	-3	17
Annual IC Cost Burden (Dollars)	5	-1	6

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.