NOTICE OF LAW ENFORCEMENT OFFICER'S INJURY OR OCCUPATIONAL DISEASE (CA-721) & NOTICE OF LAW ENFORCEMENT OFFICER'S DEATH (CA-722)

ICR 198905-1215-001

OMB: 1215-0116

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
1215-0116 198905-1215-001
Historical Active 198605-1215-010
DOL/ESA
NOTICE OF LAW ENFORCEMENT OFFICER'S INJURY OR OCCUPATIONAL DISEASE (CA-721) & NOTICE OF LAW ENFORCEMENT OFFICER'S DEATH (CA-722)
Extension without change of a currently approved collection   No
Regular
Approved without change 07/25/1989
Retrieve Notice of Action (NOA) 05/11/1989
The agency shall include the disclosure statement required at 5 CFR 1320.21 on these forms when they are next reprinted.
  Inventory as of this Action Requested Previously Approved
07/31/1992 07/31/1992 07/31/1989
75 0 75
103 0 103
0 0 0

THE FORMS ARE USED FOR FILING CLAIMS FOR COMPENSATION FOR INJURY AND DEATH TO NON-FEDERAL LAW ENFORCEMENT OFFICERS UNDER THE PROVISIONS OF USC 8191 ET SEQ. THE FORMS PROVIDE THE BASIC INFORMATION NEEDED TO PROCESS THE CLAIMS MADE FOR INJURY OR DEATH.

None
None


No

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

  Total Approved 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 75 75 0 0 0 0
Annual Time Burden (Hours) 103 103 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
05/11/1989


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