Form CA-721 Notice of Law Enforcement Officer's Injury or Occupation

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Notice of Law Enforcement Officer's
Injury Or Occupational Disease

U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs

Note: Persons are not required to respond to this collection of information unless it displays a currently
valid OMB number.

OMB No. 1215-0116
Expires: 08-31-2007

Statement of Injured Officer
1. Last, First, Middle Name of Injured Officer

2. Date of Injury (month, day, year)

4. Location Where Injury Occurred (number, street, building, city, state)

3. Hour of Injury
am
pm
5. Nature of Injury (e.g., fractured left leg)

6. Did Injury Cause Permanent Disability?
If Yes, Describe

Yes

No

7. Described Fully Why and How Injury Occurred

9. Date Signed

8. Signature

I certify that the injury described above was
sustained in performance of official duty and
occurred in such a manner as to entitle me to
benefits under 5 U.S.C. 8101 et seq. as
extended by 5 U.S.C. 8191. I hereby make
claim for compensation and medical treatment
to which I may be entitled by reason of this
injury.

10. Mailing Address Including ZIP Code

Statement of Witness
1. Describe What You Saw, Heard or Know About This Injury

2. Signature

3. Date Signed

Medical Report by Physician who First Attended Injured Officer
1. Date of First Visit
(month, day, year)

2. Nature of Injury

3. Dates of Hospitalization

4. Name and Mailing Address of Hospital

5. Type and Frequency of Treatment

6. In Your Opinion Was Disability A Result of the Injury Described In Item 7. Of the Statement of the Injured Officer?
If No, State Your Reason for Believing Officer's Disability Resulted from Other Circumstances
Yes
No

7. Type of Further Treatment Recommended

8. Signature

9. Mailing Address Including ZIP Code

10. Date Signed

Form CA-721a
Rev. Oct 2001

The Office of Workers' Compensation Programs requires this
claim before compensation can be awarded to an officer for pay
loss, permanent disability, or when the Officer is unable to
resume his regular work. The officer completes items 1 through
15 and gives it to the officer's employing organization which will
certify as to the validity of the information contained in the claim
by completing items 17, 18, and 19. If it does not agree that all
answers are correct, it should attach a detailed statement giving
the reason for its disagreement. If pay loss is involved, this claim
should not be completed until 14 calendar days have elapsed
since the beginning of the pay loss, or until the officer has
returned to work, whichever occurs first.

7. ATTENDING PHYSICIAN'S MEDICAL REPORT. If the
CLAIM FOR COMPENSATION is completed, this report is to be
completed by the physician supervising medical treatment. It is
not necessary if the CLAIM FOR COMPENSATION is not
completed.
8. SUBMITTING THIS FORM. This form should be turned over
to the employing organization. The organization will have any
remaining parts completed. Afterwards, it should review the form
for completeness and to see that all signatures appear. If a
report of investigation of any type was made on the injury or the
incident leading to injury, a copy should be attached. When the
form and any statements and attachments are ready for
transmission, this instruction page should be removed. Only one
copy of this form (the original) need be submitted.

Privacy Act
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 522a), you are hereby notified that: (1) The Federal
Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of
Workers Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information on
claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount
of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information
may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer
questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant
matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies
and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to
physicians and other health care providers for use in providing treatment or medical/vocational rehabilitation, making evaluations
for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal,
state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine
whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to
pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act.
(7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN
and/or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts
carried on by the Federal government, and for other purposes required or authorized by law. (8) Failure to disclose all requested
information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced
level of benefits.

Note: This notice applies to all forms requesting information that you might receive from the Office in connection
with the processing and adjudication of the claim you filed under the FECA.

THIS NOTICE SHOULD BE RETAINED FOR YOUR INFORMATION.

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S3229, 200
Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

All completed forms, documents, and inquiries should be sent to
Office of Workers' Compensation Programs

Washington, D.C. 20211

Employing Organization's Report
2. Name of Injury Officer's Immediate Superior

1. Name and Mailing Address Including ZIP Code of
Employing Organization

3. Name and Telephone Number of Person to Contact

4. Last, First, Middle Name of Injury Officer

5. Officer's Birth Date
(month, day, year)

7. Date Employing Organization First Received Injury
Notice
Written
Verbal
Date:

8. Name of Person to Whom Notice Was First Given

9. Date and Hour of Injury

11. Date and Hour Pay
Stopped
am/pm/

12. Date and Hour Returned
to Work
am/pm

B. Amount Paid

C. Dates For Which Leave Paid

10. Date and Hour Stopped
Work
am/pm

am/pm

13. Will Officer Receive Pay For
Any Portion of Absence From
Work Because of the Injury?
Yes

A. Types(s) of Leave

No

If Yes, Furnish
14. Rate of Pay on Date of injury

15. List and Show Value of Other Pay Increments on Date of Injury

Base

$

Per

Subsistence, If Extra

$

Per

Quarter, If Extra
16. On Day of Injury
Officer's Shift

$
a. Began
am/
pm

Per
b. Ended
am/

pm

19. Did Officer Work for the Organization a Full 11
Months Immediately Prior to Injury?
Yes

6. Social Security Number

17. Number of Hours
Worked Per Day (exclusive
of overtime)

$

Per

$

Per

18. Circle Days Normally
Worked Per Week (exclusive
of overtime) SU MO TU WE

TH

FR

20. If No, Would His Job Have Afforded Employment For 11
Months Except For the Injury?

No

21. Was Officer Performing Regular Duties When Injured?

Yes

No

Yes

No

If No, Give Full Explanation
22. Was the Injury Caused By:
a. Officer's Willful Misconduct?

Yes

No

b. Officer's Intoxication?

Yes

No

c. Officer's Intent to Bring About Injury to Self or Another (other than normally required in performance of duty)?

Yes

No

Attach Detailed Explanation for Any ''Yes'' Answers
23. If Known, Give Name and Address of Suspect(s) or Witness(es) With Whom Officer Was Involved When Injured.

24. Describe Fully How the Officer's Injury Occurred While Enforcing the Laws of the United States. If possible, give U.S. Code Citation.

25. Give Comments Regarding Completeness and Validity of the Facts Provided by Officer (attach detailed explanation if there is disagreement).

26. Signature

27. Title

28. Date Signed

SA

Claim for Compensation
1. Last, First, Middle Name of Injured Officer

2. Date of Injury (month, day, year)

3. Name of Employing Organization

4. Period Compensation is Claimed as a Result of Pay
Loss:
From

6. Was Subsistence or Quarters Furnished During Period
Shown in Item 4?
Yes
No If Yes, State
Which and Show Value and inclusive Period

5. Has Any Pay Been Claimed or Received for the Period
Yes
No If Yes, State
Shown in Item 4?
Amount and List Dates

7. Did Officer Work For Any
Other Employer During
Period Shown in Item 4?
Yes

Through

B. Amount Earned

A. Name and Address of Employer

C. Period Worked:
From

No

Through

If Yes, Furnish
8. Has Claim Been Made Against
Any Third Party For Damages
on Account of This Injury?
Yes

A. Name and Address of Party

B. Amount of Recovery Received

A. Service Number

C. Period of Service

No

if Yes, Furnish
9. Was Officer Ever in the Armed
Forces of the United States?
Yes

B. Branch of Service

From

No

Through

If Yes, Furnish
10. If Question 9 is Answered ''Yess'' Has
Application Ever Been Made for
Compensation or Pension, Including
Retirement or Retainer Pay, on Account
of Such Service?
Yes

A. Claim Number

B. Name and Address of Office
Where Claim is Filed

C. Nature of Disability and Amount of
Monthly Payment

No

If Yes, Furnish
11. Has Application Ever Been Made for
Any Annuity on Account of Officer's
Civilian Service With the United
States ?
Yes
No

A. Type of Annuity (e.g., civil service retirement)

If Yes, Furnish
12. Has Application Been Made For Compensation, Annuity, or Other Benefits as a Result of
This Injury Under Any Compensation Law, Police Disability Compensation Fund, or
Other Such Fund?
No If Yes, Give Name and Address of Organization
Yes
With Which Application Was Filed.

14. List Officer's Dependents. If None. So State
Relation ship to
Name
Officer

Date
Of
Birth

Living
With
Officer?

B. Claim Number

13. If Married, Give Date
of Officer's Marriage

If Not, Show
Mailing Address

15. For Dependents Not Living With Officer, Show Amounts That He Pays for Their Support, to Whom Paid, and Payee's Address. State Whether Such
Payments Were Ordered by A Court.

Form CA-721b
Rev. Oct 2001

STATEMENT BY EMPLOYING ORGANIZATION: We
hereby certify that the officer who executed the foregoing claim for compensation was injured while in performance of duty under 5 U.S.C. 8101 et seq. as extended by 5 U.S.C. 8191. All statements made in this
claim are true to the best of our knowledge and belief.

16. Signature

17. Date Signed

18. Title

ATTENDING PHYSICIAN'S MEDICAL REPORT
1. I certify that the above-named officer has been under my professional care for the following period for the effects of this injury.
THROUGH

FROM
2. History of Injury

3. Findings

4. Diagnosis

5. Type and Frequency of Treatment

6. Type of Further Treatment Recommended

7. In Your Opinion, Was Disability A Result of the Injury as
If No, State Your
Reported in item 2?
No
Yes
Reason For Believing Disability Resulted From Other Causes

8. Anticipated Permanent Effects

9. Other Complicating or Concurrent Diseases or Disabilities Not
Due to This Injury

10. As A Result of This Injury, Officer
Was Confined to (show dates):

11. Dates Officer Totally Disabled
For All Work

12. Date Officer May be Able to
Resume Light Work

13. Dates Officer Partially Disabled
For Usual Occupation

14. Date Officer May be Able to
Resume Regular Work

Hospital
Bed Rest at Home
Home
16. Signature
15. I certify that the answers to the above questions
are true to the best of my knowledge and belief.
I am licensed to practice medicine and surgery
in the state of

17. Date Signed

18. Mailing Address Including ZIP Code

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S3229, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

INSTRUCTIONS FOR COMPLETING THIS FORM
(Please do not detach)

1. GENERAL. This form is used to report an injury or
occupational disease sustained by a non-Federal law
enforcement officer under circumstances involving a crime
against the United States. Specifically, section 8191 of title 5,
United States Code, provides Federal workmen's compensation
benefits for a person determined to have been on any given
occasion(1) a law enforcement officer and to have been engaged on
that occasion in the apprehension or attempted
apprehension of any person(A) for the commission of a crime against the United
States, or
(B) who at that time was sought by a law enforcement
authority of the United States for the commission of a
crime against the United States, or
(C) who at that time was sought as a material witness in
a criminal proceeding instituted by the United States: or

If additional space is needed for any answer, attach a separate
sheet of paper and write, ''see separate sheet,'' in the
appropriate box of this form. Please place the name of the
injured officer (and, case file number if known) on any separate
sheets. This form must be filed with OWCP within 5 years from
the date of injury.
2. STATEMENT OF INJURED OFFICER. This statement must
be completed in all instances and only by(1) the injured officer, preferably
(2) a member of his immediate family;
(3) his guardian, personal representative, or other person
legally authorized to act on his behalf; or
(4) any association of law enforcement officers acting on his
behalf.

(2) a law enforcement officer and to have been engaged on
that occasion in protecting or guarding a person held for the
commission of a crime against the United States or as a
material witness in connection with such a crime; or

3. STATEMENT OF WITNESS. This statement normally is used
if the injury was not reported at the time that it occurred or if
some fact is not clear. It is not necessary if a report of
investigation is submitted.

(3) a law enforcement officer and to have been engaged on
that occasion in the lawful prevention of, or lawful attempt to
prevent, the commission of a crime against the United
States;

4. MEDICAL REPORT BY PHYSICIAN WHO FIRST ATTENDED
INJURED OFFICER. This report is not necessary if a more
complete medical report on this form or on another form or in
narrative is being submitted.

and to have sustained a personal injury (including disease)
related to that occasion. Federal law enforcement officers are
excluded from section 8191.

If one of the above conditions is met, this form should be filed
with the Office of Workers' Compensation Programs if the
injured officer(1) is disabled and is in a, non-pay status for more than 3
calendar days;
(2) has permanent disability;
(3) is unable to resume his regular work;
(4) incurs unpaid medical expenses; or
(5) if there is a likelihood that disability or unpaid medical
expenses will subsequently occur.
The form is designed so that the CLAIM FOR COMPENSATION
page may be detached if the claim is not needed. However, read
paragraph 6 below thoroughly before detaching the claim page.

5. EMPLOYING ORGANIZATION'S REPORT. This report must
be completed in every instance. Wage information, duty hours,
and like information should be obtained from the organization's
records. The organization must review the injured officer's
statement and the circumstances of the injury, and in item 25
should comment concerning the completeness and validity of
the officer's statement, If the organization disagrees with the
officer's statement, it should submit a detailed explanation giving
the reasons for its disagreement.

6. CLAIM FOR COMPENSATION. This claim must be completed
in every instance where the injured officer(1 ) is disabled and is in a non-pay status for more than 3
calendar days;
(2) has permanent disability; or
(3) is unable to resume his regular work.
It need not be submitted where claim is made only for medical
expenses, or if there is only a likelihood that disability or medical
expense subsequently will occur.
Form CA-721
Rev. April 1995