SUPPORTING STATEMENT
Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA-721) and Notice of Law Enforcement Officer’s Death (CA-722)
OMB No. 1215-0116
1. The Federal Employees' Compensation Act (FECA) provides, under 5 U.S.C. 8191, et.seq. and 20 CFR 10.735, that non-Federal law enforcement officers injured or killed under certain circumstances are entitled to the benefits of the Act, to the same extent as if they were employees of the Federal Government. The CA-721 and CA-722 are used by non-Federal law enforcement officers and their survivors to claim compensation under the FECA. Form CA-721 is used for claims for injury. Form CA-722 is used for claims for death. http://nt5.scbbs.com/cgi-bin/om_isapi.dll?clientID=371046&infobase=feca-act.nfo&softpage=PL_frame
2. These forms are the device by which notices of injury, claims for compensation, and claims for death benefits are filed by non-Federal law enforcement officers and their survivors. The information contained in the forms is used to help determine if the case is covered and what further issues to develop. For example, was the injury sustained under circumstances bringing it within 5 U.S.C. 8191, was the injury disabling, is the disability due to the injury, are those filing a claim entitled to compensation, what further information is required to reach a decision, etc.
3. The forms CA-721 and CA-722 can be completed on-line and printed and are available for downloading from the Internet at http://www.dol.gov/esa/regs/compliance/owcp/ca-721.pdf and http://www.dol.gov/esa/regs/compliance/owcp/ca-722.pdf.
4. The information requested on these forms is not duplicative of any information available elsewhere. The claimant, beneficiary, employer, and physician are the only sources of the required information.
5. The only involvement of small businesses is physicians who complete the medical documentation portion of the form. This information collection does not have a significant economic impact on a substantial number of small business entities.
6. The information is collected only once. Without the requested information, no determination could be made regarding the payment of benefits.
7. There are no special circumstances impacting this collection.
8. No outside consultants were contacted concerning the use of forms CA-721 and CA-722.
A notice inviting public comment on this information collection was published in the Federal Register on March 6, 2007. No comments were received.
9. No payment or gifts are provided to respondents.
10. All information contained in FECA claim files is fully protected under the Privacy Act. The forms include a Privacy Act statement. The applicable Privacy Act system of records is DOL/GOV-1.
http://www.usdoj.gov/oip/privstat.htm
http://www.dol.gov/sol/privacy/dol-govt-1.htm
11. None of these forms ask questions of a sensitive nature.
12. The response times below were based on the length of time that it will take respondents to complete the forms and obtain the necessary information. Both require full explanations of how injury or death occurred, the federal crime involved, etc.
CA-721 60 minutes 10 forms 10 hours
CA-722 90 minutes 20 forms 30 hours
Total 30 responses 40 hours
Because the wage category of the respondent is unknown, we have estimated the cost of the burden hours using the National Average Weekly Wage median wages of productions workers as computed by BLS, or $11.36 per hour ($11.36 X 40 hours = $454.40). http://www.bls.gov/oes/current/oes519199.htm
13. The only operation and maintenance cost is for mailing. There are 30 annual responses, at ($.41 postage and $.03 for envelope per response) 30 x $.44 = $13.20.
14. Federal Cost Estimate:
Printing Costs: Due to the small number of claims received, there are no plans to print the form in bulk for distribution
Mailing and Developmental Costs: Claimants and employers are able to download forms CA-721 and CA-722 directly from the internet; therefore, no mailing costs for the forms will be incurred. However, development usually occurs in these types of cases, therefore, mailing costs for development of the claim =
($.41 postage and $.03 for envelope per response) 30 x $.44 = $13.20.
Processing Cost: All claims are reviewed and adjudicated by Claims Examiners located in the Cleveland District Office with an average grade of GS-12 step 5 at an hourly rate hourly wage of $35.45
30 Forms X 1/3 of an hour each X 35.45 = $367.70
The Federal cost for mailing and processing of claims is $367.10.
http://www.opm.gov/oca/07tables/pdf/cle_h.pdf
http://www.opm.gov/oca/07tables/html/cle.asp
15. There is an increase in burden hours due to an increase in claims that have been filed which is an adjustment of +9 burden hours. There has been an increase in the operation and maintenance cost because of an increase in the cost of postage.
Data collected with these forms will not be published.
The form will display the expiration date.
There are no exceptions to certification.
| File Type | application/msword |
| File Title | Supplemental Statement |
| Author | US Department of Labor |
| Last Modified By | U.S. Department of Labor |
| File Modified | 2007-05-30 |
| File Created | 2007-05-30 |