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 201609-1240-001 · 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
Section 8191 reference omb 1240-0022.doc Supplementary Document Uploaded 2016-09-01 Available
OPM Salary table 2016-0022 for cleveland.pdf Supplementary Document Uploaded 2016-09-01 Repair queued
eCFR — Code of Federal Regulations.mjs 2016 for ca-721 and ca-722.docx Supplementary Document Uploaded 2016-09-01 Available
Privacy Act Systems.doc Supplementary Document Uploaded 2016-09-01 Repair queued
BLS Salary Data for omb 1240-0022-2016.doc Supplementary Document Uploaded 2016-09-01 Available
SS for 1240-0022 (CA-721 and 722) 2016.doc Supporting Statement A Uploaded 2016-12-21 Repair queued
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 201609-1240-001
Historical Active 201306-1240-006
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 03/06/2017
Retrieve Notice of Action (NOA) 12/30/2016
  Inventory as of this Action Requested Previously Approved
03/31/2020 36 Months From Approved 03/31/2017
7 0 10
9 0 14
4 0 5
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
  81 FR 69087 10/05/2016
81 FR 97111 12/30/2016
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 7 10 0 0 -3 0
Annual Time Burden (Hours) 9 14 0 0 -5 0
Annual Cost Burden (Dollars) 4 5 0 0 -1 0
No
No
The previous approved number of annual respondents (10) is now 7, which represents a decrease of 3. The previously approved number for burden hours was 14, and the requested number now is 9, a decrease of 5. The annual cost burden decreased from $5.00 (previous reporting) to $4.00, which is an adjustment of $1.00. Revision to the forms solely involved the accommodation language.
$107
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.
12/30/2016