Information Collection

Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)

IC 13785 under ICR 201003-1240-022 · OMB 1240-0022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0022 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
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
CA-721 Notice of Law Enforcement Officer's Injury or Occupation CA-721.pdf www.dol.gov/esa/regs/compliance/owcp/ca-721.pdf	Form and Instruction
CA-722 Notice of Law Enforcement Officer's Death CA-722.pdf www.dol.gov/esa/regs/compliance/owcp/ca-722.pdf	Form and Instruction

IC Title:

Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.735

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-721	Notice of Law Enforcement Officer's Injury or Occupational Disease	CA-721.pdf	http://www.dol.gov/esa/regs/compliance/owcp/ca-721.pdf	Yes	No	Fillable Printable
Form and Instruction	CA-722	Notice of Law Enforcement Officer's Death	CA-722.pdf	http://www.dol.gov/esa/regs/compliance/owcp/ca-722.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 67 FR 16826

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30	7	23
Annual IC Time Burden (Hours)	40	9	31
Annual IC Cost Burden (Dollars)	13	13	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.