Public Safety Officers' Disability Beneftis Application

Section/Heading	Subheading	Modal?	Question	Field Type	Answer Choices (If applicable)	Required/Not Required	Instructional Text
Consent to Release Information and Assistance with Your PSOB Application							The Public Safety Officers’ Benefits (PSOB) Office collaborates with various PSOB National Stakeholders, including the Concerns of Police Survivors, Inc. (C.O.P.S.) and National Fallen Firefighters Foundation (NFFF), to provide information and support to survivors and surviving agencies of America’s fallen and catastrophically injured Public Safety Officers. With funding from the Bureau of Justice Assistance, C.O.P.S. and NFFF provide a wide range of peer support and counseling services to survivors, as well as assistance with filing a PSOB application. By completing the consent to release below, you authorize the PSOB Office to release your name and contact information to C.O.P.S., NFFF, or any other organization you specify to contact you for assistance with your application.
			Pursuant to the Privacy Act (5 U.S.C. § 552a(b)), I consent to the release of my name and contact information to: Concerns of Police Survivors, Inc. (https://www.nationalcops.org).	Radio	Yes/No	Required
			Pursuant to the Privacy Act (5 U.S.C. § 552a(b)), I consent to the release of my name and contact information to: National Fallen Firefighters Foundation https://www.firehero.org).	Radio	Yes/No	Required
			Other Organization (please specify)	Text Box	NA	Not Required
In which capacity are you filing this application?
			Applicant Type	Radio	Applicant/Authorized Representative	Required
What type of Authorized Representative are you?			Authorized Representative Type	Radio	Attorney/Other	Required
			If "other" selected, describe the relationship to the Applicant:	Text Box	NA	Required (if "Other" is chosen)
Enter the Public Safety Officer's information.
			Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other(please describe)	Not Required
			Describe "other" here	Text Box		Required (if "other" is chosen)
			Public Safety Officer First Name	Text Box	NA	Required
			Public Safety Officer Middle Name	Text Box	NA	Not Required
			Public Safety Officer Last Name	Text Box	NA	Required
			Public Safety Officer Suffix	Text Box	NA	Not Required
			Public Safety Officer Job Title	Text Box	NA	Required
			Public Safety Officer Employing Agency	Text Box	NA	Required
			Public Safety Officer Social Security Number (Enter in this format: 555-55-5555)	Text Box	NA	Required
			Public Safety Officer Date of Birth	Text Box/Date Picker	NA	Required
			Public Safety Officer Date of Injury	Text Box/Date Picker	NA	Required
			Public Safety Officer Date of Medical Retirement	Text Box/Date Picker	NA	Not Required
			Public Safety Officer Address Line 1	Text Box	NA	Required
			Public Safety Officer Address Line 2	Text Box	NA	Not Required
			Public Safety Officer City	Text Box	NA	Required
			Public Safety Officer State	Dropdown	Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa Guam Northern Mariana Islands Puerto Rico (PR) US Virgin Islands Other (outside U.S. Territories)	Required
			Describe "other" here	Text Box	NA	Only required if "other" chosen in previous question.
			Public Safety Officer Country	Text Box	NA	Not Required
			Public Safety Officer Zip/Postal Code	Text Box	NA	Required
			Public Safety Officer Phone Number	Text Box	NA	Required
			Public Safety Officer Alternate Phone Number	Text Box	NA	Not Required
			Public Safety Officer Email Address	Text Box	NA	Required
Officer Injury Profile
			Cause of Injury: (Check all that apply)	Checkbox	Bullets Explosives Sharp Instruments/ Blunt Objects Physical Blows Motor Vehicle/ Boat/ Airplane/ Helicopter Accident Fire/ Smoke Inhalation Chemicals Electricity Climatic Conditions Infectious Disease Radiation Viral Infection Heart Attack Stroke Vascular Rupture Occupational Disease Stress or Strain Other (please describe)	Required
			Describe "other" here:	Text Box	NA	Only required if "other" is chosen as the answer to the previous question.
			Was this injury related to the events of September 11, 2001?	Radio	Yes/No	Required
			At the time of injury, was the Officer:	Radio	On-duty, Off-duty, Other (please describe)	Required
			Describe "other" here:	Text Box	NA	Only required if "other" is chosen as the answer to the previous question.
			Was the Public Safety Officer married at the time of injury?	Radio	Yes/No	Required
Enter information about the Public Safety Officer's Spouse
			How many times was the Public Safety Officer married?	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required
		"Add Officer's Spouse" modal
	Add Spouse of Public Safety Officer		Prefix	Dropdown	Mr., Mrs., Ms., Miss, Dr., Other (please describe)	Not Required
			Describe "other" here:	Text Box	NA	Only required if "other" is chosen as the answer to the previous question.
			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Did the Public Safety Officer have any Children at the time of injury?	Radio	Yes/No	Required
Add information about all of the Officer's Children
			How many Children does the Public Safety Officer have?	Dropdown	0,1,2,3,4,5,6,7,8,9,10+	Required
		"Add Child" modal
Add Child of Public Safety Officer			First Name	Text Box	NA	Required
			Middle Name	Text Box	NA	Not Required
			Last Name	Text Box	NA	Required
			Suffix	Text Box	NA	Not Required
			Date of Birth	Text Box/Date Picker	NA	Not Required
Other Benefits
			Has a claim for benefits been filed under any of the following: (Check all that apply)	Checkbox	Medical Retirement/Disability Workers' Compensation Social Security Federal Employees Compensation Act D.C. Retirement and Disability Act of September 1, 1916 September 11th Victim Compensation Fund Other (please describe) None of the Above (please describe)	Required
			Describe "other" or "none of the above" here:	Text Box	NA	Only required if other or none of the above was chosen in the previous question
			Has a final determination been issued for any of the following: (Check all that apply)	Checkbox	Medical Retirement/Disability Workers' Compensation Social Security Federal Employees Compensation Act D.C. Retirement and Disability Act of September 1, 1916 September 11th Victim Compensation Fund Other (please describe) None of the Above (please describe)	Required
			Describe "other" or "none of the above" here:	Text Box	NA	Only required if other or none of the above was chosen in the previous question
Applicant's Statement							Answer the following questions in the text box provided below.
			What is the highest educational level the Officer achieved? Has the Officer completed any special training or courses, including military training?	Text Box	NA	Required
			Has the Officer received any formal vocational or functional capacity evaluation or vocational rehabilitative treatment?	Radio	Yes/No	Required
			Has the Officer worked at any job following the injuries?	Radio	Yes/No	Required
			If so, where?	Text Box	NA	Only required if other was chosen in the previous question
			Is the Officer currently working or volunteering in any capacity?	Radio	Yes/No	Required
			If yes, please describe.	Text Box	NA	Only required if yes was chosen in the previous question
APPLICATION PREVIEW	Please Review and Confirm						The following is a summary of the information you have entered. Please review and make any necessary changes to this page before submitting your application.
Required Documents							Based on your responses, a customized checklist has been generated. The following required documents must be uploaded for the application to be considered complete. If you have any questions, please contact the PSOB Customer Resource Center at 1-888-744-6513 or [email protected].
			Association	Static Text Box	NA	Auto filled
			Document Type	Static Text Box	NA	Auto filled
			Date Uploaded	Static Text Box	NA	Auto filled
			Instructions	Static Text Box	NA	Auto filled	All doc instructions are located in the "Required Documents and Instructions" tab
			Review Status	Static Text Box	NA	Auto filled
			Add document clarifying notes if necessary.	Text Box	NA	Not Required
			Missing Document Justification	Text Box	NA	Required only if a required document is not uploaded
		"Click here to Add Other Documentation" modal
Missing Documents							Your application is missing one or more required documents needed to successfully submit your application. Please go to the previous screen to review the list of required documents, to upload all required documents or to provide an explanation of why a document is missing.
CERTIFICATION OF APPLICATION							The information provided will be used by the Department of Justice to determine eligibility of an Applicant/Claimant for PSOB Program benefits. To verify eligibility for benefits, the information provided is subject to investigation and may be disclosed to federal, state, tribal, and local agencies to verify eligibility for benefits. If the Department of Justice receives adverse information regarding an Applicant’s or Claimant’s eligibility, an information of record may be disclosed as necessary to affected persons and federal, state, tribal, and local agencies, including those persons or agencies challenging eligibility. I certify that all of the information provided is correct and complete to the best of my knowledge. I know of no facts or circumstances that would render the person identified here as ineligible for the benefit. I understand that knowingly and willfully making a false or incomplete statement or failing to fully disclose pertinent information concerning this claim may be grounds for non-payment of benefits or for prosecution for a false statement under 18 U.S.C. § 1001. Checking the box below asserts that you have read and understand this Certification of Application, and will be treated as an electronic signature by or on behalf of the Applicant. If you are ready to submit your application, click the “Next/Save” button. If you need to make changes to your application, click the “Previous” button.
FINAL REVIEW FORM	Please Review and Confirm						This final review form serves as the version of the application you are about to submit. If you wish to make edits, return to the editable preview screen to do so.
Application Part A Successfully Submitted							Application Part A Successfully Submitted A PSOB Disability Benefits Application consists of two parts, Part A and Part B. Part A is completed by the Officer or Authorized Representative, Part B is completed by the Employing Agency. Parts A and B, and all required supporting documents must be provided before the application can be considered complete. A Customer Resource Specialist will review the application. If all required documents are provided, the application will be assigned a claim number and will move to the next stage of review. If the contact information you initially provided changes, please log into the PSOB portal to update your contact details.