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 202410-1240-001 · OMB 1240-0022 · Received in OIRA

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
Justification for Nonstantive change for the CA-722.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-10-16 Missing upstream
Justification for Nonsubstantive change for the CA-721.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-10-16 Repair queued
5 USC 8191.docx Supplementary Document Uploaded 2023-07-31 Repair queued
eCFR _ Code of Federal Regulations for ca-721 and ca-722 for 2023.docx Supplementary Document Uploaded 2023-07-31 Repair queued
88 Fed Register 29696 (Publised May 8 2023.pdf Supplementary Document Uploaded 2023-07-31 Repair queued
San Francisco OPM Salary Table. 2023.pdf Supplementary Document Uploaded 2023-05-18 Missing upstream
Rest of U.S. - Jacksonville OPM Salary Table. 2023.pdf Supplementary Document Uploaded 2023-05-18 Repair queued
Boston OPM Salary Table. 2023.pdf Supplementary Document Uploaded 2023-05-18 Repair queued
Atlanta OPM Salary Table. 2023.pdf Supplementary Document Uploaded 2023-05-18 Missing upstream
Cleveland OPM Salary Table. 2023.pdf Supplementary Document Uploaded 2023-05-18 Missing upstream
Production Workers, All Others, May 2021.pdf Supplementary Document Uploaded 2023-05-18 Repair queued
1240-0022 Supporting Statement_FINAL_20230905.docx Supporting Statement A Uploaded 2023-09-05 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 202410-1240-001
Received in OIRA 202305-1240-001
DOL/OWCP
Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death
No material or nonsubstantive change to a currently approved collection   No
Regular 10/24/2024
  Requested Previously Approved
10/31/2026 10/31/2026
2 2
3 3
3 3
This nonsub change request is being submitted to changed the mailing address for the forms. 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
  88 FR 29696 05/08/2023
88 FR 62601 09/12/2023
No
  Total Request 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 2 2 0 0 0 0
Annual Time Burden (Hours) 3 3 0 0 0 0
Annual Cost Burden (Dollars) 3 3 0 0 0 0
No
No
$34
No
    Yes
    Yes
No
No
No
No
Pamela Hamai 415 241-3350 [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.
10/24/2024