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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 201911-1240-006 · OMB 1240-0022 · 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
1240-0022 Supporting Stmt.docx Supporting Statement A Uploaded 2020-03-30 Available
81 Fed. Reg 47418 (July 21, 2016).pdf Supplementary Document Uploaded 2020-01-08 Repair queued
Section 8191 reference omb 1240-0022.doc Supplementary Document Uploaded 2019-11-27 Repair queued
CLE_h opm salary 2019.pdf Supplementary Document Uploaded 2019-11-27 Available
eCFR _ Code of Federal Regulations.mjs 2016 for ca-721 and ca-722 for 2019.docx Supplementary Document Uploaded 2019-11-27 Repair queued
Production Workers, all others.docx Supplementary Document Uploaded 2019-11-27 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 201911-1240-006
Active 201609-1240-001
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 10/22/2020
Retrieve Notice of Action (NOA) 03/30/2020
  Inventory as of this Action Requested Previously Approved
10/31/2023 36 Months From Approved 10/31/2020
6 0 7
6 0 9
4 0 4
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. The program requests clearance by the expiration date of March 31, 2020.
US Code: 5 USC 8191 Name of Law: The Federal Employee's Compensation Act
  
None
Not associated with rulemaking
  85 FR 4341 01/24/2020
85 FR 17366 03/27/2020
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 6 7 0 0 -1 0
Annual Time Burden (Hours) 6 9 0 0 -3 0
Annual Cost Burden (Dollars) 4 4 0 0 0 0
No
No
The previous approved number of annual respondents (7) is now 6, which represents a decrease of 1. The previously approved number for burden hours was 9, and the requested number now is 6, a decrease of 3. All of the initial claims submitted for calendar years 2016-2018 were for claimed injuries or occupational diseases. The decrease in annual respondents is because no death claims were created for calendar years 2016-2018.
$101
No
    Yes
    Yes
No
No
No
No
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.
03/30/2020