Information Collection

Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)

IC 13785 under ICR 202607-1240-002 · OMB 1240-0022.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CA-721 Notice of Law Enforcement Officer's Injury or Occupational Disease Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)	Form and Instruction
Form CA-722 Notice of Law Enforcement Officer's Death Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722)	Form and Instruction
CA-721 Notice of Law Enforcement Officer's Injury or Occupation CA-721 expires 10.31.2026.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction
CA-722 Notice of Law Enforcement Officer's Death CA-722 expires 10.31.2026.pdf www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.735

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CA-721			http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable
Form and Instruction	CA-722			http://www.dol.gov/owcp/dfec/regs/compliance/forms.htm	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: DOL/GOVT-1

FR Citation: 81 FR 47418

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4	2	2
Annual IC Time Burden (Hours)	5	2	3
Annual IC Cost Burden (Dollars)	3	0	3

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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