Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death

ICR 202208-1240-001

OMB: 1240-0022

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
 Unchanged
Justification for No Material/Nonsubstantive Change
2022-08-02
Supplementary Document
2022-08-02
Supporting Statement B
2022-08-01
Supporting Statement A
2022-08-02
Supplementary Document
2020-01-08
Supplementary Document
2019-11-27
Supplementary Document
2019-11-27
Supplementary Document
2019-11-27
Supplementary Document
2019-11-27
IC Document Collections
IC ID
Document
Title
Status
13785 Unchanged
ICR Details
1240-0022 202208-1240-001
Received in OIRA 201911-1240-006
DOL/OWCP
Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death
No material or nonsubstantive change to a currently approved collection   No
Regular 08/04/2022
  Requested Previously Approved
10/31/2023 10/31/2023
6 6
6 6
4 4
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. The No material/Nonsubstantive Change is requests that the address be revised on page 6 of the form which requires that the completed form be sent to OWCP. The new Division is now noted as OWCP Division of Federal Employees', Longshore and Harbor Workers' Compensation (DFELHWC). The address on page 6 should now be noted as Office of Workers' Compensation Programs, Division of Federal Employees', Longshore and Harbor Workers' Compensation, Federal Employees' Compensation Act, (OWCP/DFELHWC-FECA), PO Box 8311, London, KY 4072-8311.
US Code: 5 USC 8191 Name of Law: The Federal Employee's Compensation Act
  
None
Not associated with rulemaking
  85 FR 4341 01/24/2020
85 FR 17366 03/27/2020
No
  Total Request 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 6 6 0 0 0 0
Annual Time Burden (Hours) 6 6 0 0 0 0
Annual Cost Burden (Dollars) 4 4 0 0 0 0
No
No
The previous approved number of annual respondents (7) is now 6, which represents a decrease of 1. The previously approved number for burden hours was 9, and the requested number now is 6, a decrease of 3. All of the initial claims submitted for calendar years 2016-2018 were for claimed injuries or occupational diseases. The decrease in annual respondents is because no death claims were created for calendar years 2016-2018.
$101
No
    Yes
    Yes
No
No
No
No
Marcus Sharpless 202 693-0998 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/04/2022
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