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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-722 Notice of Law Enforcement Officer's Death	Form and Instruction	Modified	Available
Form CA-721 Notice of Law Enforcement Officer's Injury or Occupational Disease	Form and Instruction	Modified	Available
5 USC 8191.docx	Supplementary Document	Uploaded 2026-07-14	Available
eCFR _ Code of Federal Regulations for ca-721 and ca-722 for 2026.docx	Supplementary Document	Uploaded 2026-07-14	Available
Privacy Act Systems of Records DOL-GOVT-1.docx	Supplementary Document	Uploaded 2026-07-14	Available
OPM 2026 Salary Table. Washington DC.pdf	Supplementary Document	Uploaded 2026-07-14	Available
OPM 2026 Salary Table. San Francisco.pdf	Supplementary Document	Uploaded 2026-07-14	Available
OPM 2026 Salary Table. San Antonio.pdf	Supplementary Document	Uploaded 2026-07-14	Available
OPM 2026 Salary Table. RUS.pdf	Supplementary Document	Uploaded 2026-07-14	Available
OPM 2026 Salary Table. Dallas.pdf	Supplementary Document	Uploaded 2026-07-14	Available
OPM 2026 Salary Table. Boston.pdf	Supplementary Document	Uploaded 2026-07-14	Available
OPM 2026 Salary Table. Cleveland.pdf	Supplementary Document	Uploaded 2026-07-14	Available
BLS Production Worker.pdf	Supplementary Document	Uploaded 2026-07-14	Available
1240-0022 Supporting Statement. updated 07.14.2026.docx	Supporting Statement A	Uploaded 2026-07-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
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	Notice of Law Enforcement Officer's Death
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	Notice of Law Enforcement Officer's Injury or Occupational Disease

ICR Details

OMB Control No: 1240-0022	ICR Reference No: 202607-1240-002
Status: Received in OIRA	Previous ICR Reference No: 202410-1240-001
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: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/29/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	4	2
Time Burden (Hours)	5	3
Cost Burden (Dollars)	3	3

---

Abstract: The Federal Employees’ Compensation Act (FECA) provides, under 5 U.S.C. 8191, et.seq. and 20 CFR 10.735, that non-Federal law enforcement officers injured or killed under certain circumstances are entitled to the benefits of the Act, to the same extent as if they were employees of the Federal Government. The CA-721 and CA-722 are used by non-Federal law enforcement officers and their survivors to claim compensation under the FECA. Form CA-721 is used for claims for injury. Form CA-722 is used for claims for death. The authority for this collection is 5 U.S.C. 8191-8193.

---

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

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 25387	05/08/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 61451	09/29/2026
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

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

---

ICR Summary of Burden

table that charts list of burden

	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	4	2	0	2	0	0
Annual Time Burden (Hours)	5	3	0	2	0	0
Annual Cost Burden (Dollars)	3	3	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Respondents: The number of respondents increased from 2 to 4. This increase in respondents was due to more forms being received. Responses: The number of responses increased from 2 to 4 due to an increase in respondents. Burden Hours: The total number of burden hours increased from 0.3333 hours to 1.333 hours due to the increase in respondents. Costs to Respondents or Recordkeepers: No change. The prior SS showed $1.00. However, the prior ROCIS entry showed $3.00 which is the same as this ICR extension. 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.

---

Annual Cost to Federal Government: $71

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

---

Common Form ICR:  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:

(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: 09/29/2026

---