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
Section 8191 reference omb 1240-0022.doc Supplementary Document	2016-09-01
OPM Salary table 2016-0022 for cleveland.pdf Supplementary Document	2016-09-01
eCFR — Code of Federal Regulations.mjs 2016 for ca-721 and ca-722.docx Supplementary Document	2016-09-01
Privacy Act Systems.doc Supplementary Document	2016-09-01
BLS Salary Data for omb 1240-0022-2016.doc Supplementary Document	2016-09-01
SS for 1240-0022 (CA-721 and 722) 2016.doc Supporting Statement A	2016-12-21

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: 201609-1240-001
Status: Historical Active	Previous ICR Reference No: 201306-1240-006
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: 03/06/2017
	Date Received in OIRA: 12/30/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2020	36 Months From Approved	03/31/2017
Responses	7	0	10
Time Burden (Hours)	9	0	14
Cost Burden (Dollars)	4	0	5

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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:
	81 FR 69087	10/05/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 97111	12/30/2016
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	7	10	0	0	-3	0
Annual Time Burden (Hours)	9	14	0	0	-5	0
Annual Cost Burden (Dollars)	4	5	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 (10) is now 7, which represents a decrease of 3. The previously approved number for burden hours was 14, and the requested number now is 9, a decrease of 5. The annual cost burden decreased from $5.00 (previous reporting) to $4.00, which is an adjustment of $1.00. Revision to the forms solely involved the accommodation language.

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Annual Cost to Federal Government: $107

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: 12/30/2016

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