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Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)
Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death
OMB: 1240-0022
IC ID: 13785
OMB.report
DOL/OWCP
OMB 1240-0022
ICR 201306-1240-006
IC 13785
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0022 can be found here:
2023-09-12 - Extension without change of a currently approved collection
2022-08-04 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
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 revised.pdf
www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Form and Instruction
CA-722 Notice of Law Enforcement Officer's Death
ca-722 revised.pdf
www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
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:
Voluntary
CFR Citation:
20 CFR 10.735
Information Collection 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 revised.pdf
http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Yes
No
Fillable Printable
Form and Instruction
CA-722
Notice of Law Enforcement Officer's Death
ca-722 revised.pdf
http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
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:
10
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
10
0
0
-3
0
13
Annual IC Time Burden (Hours)
14
0
0
-3
0
17
Annual IC Cost Burden (Dollars)
5
0
0
-1
0
6
Documents for IC
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.