Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death

Forms and Documents

Document Name	Status
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
Justification for Nonstantive change for the CA-722.docx Justification for No Material/Nonsubstantive Change	2024-10-16
Justification for Nonsubstantive change for the CA-721.docx Justification for No Material/Nonsubstantive Change	2024-10-16
5 USC 8191.docx Supplementary Document	2023-07-31
eCFR _ Code of Federal Regulations for ca-721 and ca-722 for 2023.docx Supplementary Document	2023-07-31
88 Fed Register 29696 (Publised May 8 2023.pdf Supplementary Document	2023-07-31
San Francisco OPM Salary Table. 2023.pdf Supplementary Document	2023-05-18
Rest of U.S. - Jacksonville OPM Salary Table. 2023.pdf Supplementary Document	2023-05-18
Boston OPM Salary Table. 2023.pdf Supplementary Document	2023-05-18
Atlanta OPM Salary Table. 2023.pdf Supplementary Document	2023-05-18
Cleveland OPM Salary Table. 2023.pdf Supplementary Document	2023-05-18
Production Workers, All Others, May 2021.pdf Supplementary Document	2023-05-18
1240-0022 Supporting Statement_FINAL_20230905.docx Supporting Statement A	2023-09-05

IC Document Collections

IC ID	Document Title	Status
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

OMB Control No: 1240-0022	ICR Reference No: 202410-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202305-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/24/2024

	Requested	Previously Approved
Expiration Date	10/31/2026	10/31/2026
Responses	2	2
Time Burden (Hours)	3	3
Cost Burden (Dollars)	3	3

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Abstract: 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.

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Authorizing Statute(s): US Code: 5 USC 8191 Name of Law: The Federal Employee's Compensation Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 29696	05/08/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 62601	09/12/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)	CA-721, CA-722	Notice of Law Enforcement Officer's Injury or Occupational Disease ,   Notice of Law Enforcement Officer's Death

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $34

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/24/2024

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