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 202305-1240-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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.docx www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-721 Notice of Law Enforcement Officer's Injury or Occupation ca-721.docx www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-722 Notice of Law Enforcement Officer's Death ca-722.docx www.dol.gov/owcp/dfec/regs/compliance/forms.htm Form and Instruction
CA-722 Notice of Law Enforcement Officer's Death ca-722.docx 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: Required to Obtain or Retain Benefits

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.docx	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.docx	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: 81 FR 47418

Number of Respondents: 2	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2	-4	6
Annual IC Time Burden (Hours)	3	-3	6
Annual IC Cost Burden (Dollars)	3	-1	4

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.