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Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 1240-0022 · DOL/OWCP.

OMB 1240-0022

This nonsub change request is being submitted to changed the mailing address for the forms. 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 latest form for Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death expires 2026-10-31 and is listed under ICR 202410-1240-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CA-722 Notice of Law Enforcement Officer's DeathForm and Instruction
Form CA-721 Notice of Law Enforcement Officer's Injury or Occupational DiseaseForm and Instruction
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
Justification for Nonstantive change for the CA-722.docxJustification for No Material/Nonsubstantive Change
Justification for Nonstantive change for the CA-722.docx Justification for No Material/Nonsubstantive Change
Justification for Nonsubstantive change for the CA-721.docxJustification for No Material/Nonsubstantive Change
Justification for Nonsubstantive change for the CA-721.docx Justification for No Material/Nonsubstantive Change
5 USC 8191.docxSupplementary Document
5 USC 8191.docx Supplementary Document
eCFR _ Code of Federal Regulations for ca-721 and ca-722 for 2023.docxSupplementary Document
88 Fed Register 29696 (Publised May 8 2023.pdfSupplementary Document
88 Fed Register 29696 (Publised May 8 2023.pdf Supplementary Document
San Francisco OPM Salary Table. 2023.pdfSupplementary Document
San Francisco OPM Salary Table. 2023.pdf Supplementary Document
Rest of U.S. - Jacksonville OPM Salary Table. 2023.pdfSupplementary Document
Rest of U.S. - Jacksonville OPM Salary Table. 2023.pdf Supplementary Document
Boston OPM Salary Table. 2023.pdfSupplementary Document
Boston OPM Salary Table. 2023.pdf Supplementary Document
Atlanta OPM Salary Table. 2023.pdfSupplementary Document
Atlanta OPM Salary Table. 2023.pdf Supplementary Document
Cleveland OPM Salary Table. 2023.pdfSupplementary Document
Cleveland OPM Salary Table. 2023.pdf Supplementary Document
Production Workers, All Others, May 2021.pdfSupplementary Document
Production Workers, All Others, May 2021.pdf Supplementary Document
1240-0022 Supporting Statement_FINAL_20230905.docxSupporting Statement A
1240-0022 Supporting Statement_FINAL_20230905.docxSupporting 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
Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722) Form and Instruction
Notice of Law Enforcement Officer's Injury or Occupational Disease (CA-721); Notice of Law Enforcement Officer's Death (CA-722) Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202410-1240-001 No material or nonsubstantive change to a currently approved collection 2024-10-24 Approved without change
202305-1240-001 Extension without change of a currently approved collection 2023-09-12 Approved without change
202208-1240-001 No material or nonsubstantive change to a currently approved collection 2022-08-04 Approved without change
201911-1240-006 Revision of a currently approved collection 2020-03-30 Approved without change
201609-1240-001 Revision of a currently approved collection 2016-12-30 Approved without change
201306-1240-006 Revision of a currently approved collection 2013-10-30 Approved without change
201004-1240-011 Revision of a currently approved collection 2010-08-06 Approved without change
201003-1240-022 Extension without change of a currently approved collection 2010-03-12 Approved without change