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

ICR 202305-1240-001

OMB: 1240-0022

Federal Form Document

Forms and Documents
ICR Details
1240-0022 202305-1240-001
Received in OIRA 202208-1240-001
Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death
Extension without change of a currently approved collection   No
Regular 09/12/2023
  Requested Previously Approved
36 Months From Approved 10/31/2023
2 6
3 6
3 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 program requests clearance by the expiration date of October 31, 2023.

US Code: 5 USC 8191 Name of Law: The Federal Employee's Compensation Act

Not associated with rulemaking

  88 FR 29696 05/08/2023
88 FR 62601 09/12/2023

  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 2 6 0 -4 0 0
Annual Time Burden (Hours) 3 6 0 -3 0 0
Annual Cost Burden (Dollars) 3 4 0 -1 0 0
Miscellaneous Actions
The previous approved number of annual respondents (6) is now 2, which represents a decrease of 4. The previously approved number for burden hours was 6, and the requested number now is 2, a decrease of 4. The number of these claims will remain low as jurisdictions are using less non-federal law enforcement officers to assist in circumstances involving a crime against the United States. There are no changes to either form.

Pamela Hamai 415 241-3350 [email protected]


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.

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