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

OMB 1240-0022

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 March 31, 2020.

The latest form for Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death expires 2023-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CA-721 Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722) Form and Instruction
5 USC 8191.docx Supplementary Document
eCFR _ Code of Federal Regulations for ca-721 and ca-722 for 2023.docx Supplementary Document
88 Fed Register 29696 (Publised May 8 2023.pdf Supplementary Document
San Francisco OPM Salary Table. 2023.pdf Supplementary Document
Rest of U.S. - Jacksonville OPM Salary Table. 2023.pdf Supplementary Document
Boston OPM Salary Table. 2023.pdf Supplementary Document
Atlanta OPM Salary Table. 2023.pdf Supplementary Document
Cleveland OPM Salary Table. 2023.pdf Supplementary Document
Production Workers, All Others, May 2021.pdf Supplementary Document
1240-0022 Supporting Statement_FINAL_20230905.docx Supporting Statement A
Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722) Form and Instruction

202305-1240-001 Approved without change	Extension without change of a currently approved collection	2023-09-12
202208-1240-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2022-08-04
201911-1240-006 Approved without change	Revision of a currently approved collection	2020-03-30
201609-1240-001 Approved without change	Revision of a currently approved collection	2016-12-30
201306-1240-006 Approved without change	Revision of a currently approved collection	2013-10-30
201004-1240-011 Approved without change	Revision of a currently approved collection	2010-08-06
201003-1240-022 Approved without change	Extension without change of a currently approved collection	2010-03-12