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
dol-govt-1.doc Supplementary Document	2013-06-18
Section 8191.doc Supplementary Document	2013-06-18
eCFR — Code of Federal Regulations.mht Supplementary Document	2013-06-18
BLS Salary Data.doc Supplementary Document	2013-06-18
2013 OPM Salary Table-Cleveland.pdf Supplementary Document	2013-06-18
SS for 1240-0022 (CA-721 and 722) 2013.doc Supporting Statement A	2013-10-21

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: 201306-1240-006
Status: Historical Active	Previous ICR Reference No: 201004-1240-011
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/27/2013
	Date Received in OIRA: 10/30/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	36 Months From Approved	12/31/2013
Responses	10	0	13
Time Burden (Hours)	14	0	17
Cost Burden (Dollars)	5	0	6

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Abstract: 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:
	78 FR 40513	07/05/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 64979	10/30/2013
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 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	10	13	0	0	-3	0
Annual Time Burden (Hours)	14	17	0	0	-3	0
Annual Cost Burden (Dollars)	5	6	0	0	-1	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: The previous approved number of annual respondents (13), is now 10, which represents a decrease of 3. The previously approved number for burden hours was 17, and the requested number now is 14, a decrease of 3. The annual cost burden decreased from $6.00 (previous reporting) to $5.00, which is an adjustment of $1.00. As a result of the Department of Treasury now requiring all federal benefits payments to be made electronically, the CA-721 and CA-722 were revised to include space for claimants/beneficiaries to complete information related to direct deposit. The instructions to these forms were also revised regarding this requirement. Also, rather than requesting signature of the claimant, the CA-722 was revised to request signature of the person filing the claim. Additionally, both forms were revised to include an accommodation statement to inform claimants who have mental or physical limitations to contact DFEC if further assistance is needed with the claims process.

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Annual Cost to Federal Government: $142

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

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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: 10/30/2013

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