Fillable Notice of Law Enforcement Officer's Injury Or Occupational (Department of Labor)

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Notice of Law Enforcement Officer's Injury Or Occupational (Department of Labor)

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Page 1 of 6
4. Name and Mailing Address of Hospital
3. Date Signed
10. Mailing Address Including ZIP Code
1. Last, First, Middle Name of Injured Officer
Notice of Law Enforcement Officer's
Injury Or Occupational Disease
U.S. Department of Labor
Office of Workers' Compensation Programs
Note: Persons are not required to respond to this collection of information unless it displays a currently
valid OMB number.
OMB No. 1240-0022
Expires: 07/31/2020
Statement of Injured Officer
2. Date of Injury (month, day, year)
3. Hour of Injury 4. Location Where Injury Occurred (number, street, building, city, state)
5. Nature of Injury (e.g., fractured left leg) 6. Did Injury Cause Permanent Disability?
If Yes, Describe
7. Describe Fully Why and How Injury Occurred
I certify that the injury described above was
sustained in performance of official duty and
occurred in such a manner as to entitle me to
benefits under 5 U.S.C. 8101 et seq. as
extended by 5 U.S.C. 8191. I hereby make
claim for compensation and medical treatment
to which I may be entitled by reason of this
injury.
8. Signature 9. Date Signed
Statement of Witness
1. Describe What You Saw, Heard or Know About This Injury 2. Signature
Medical Report by Physician who First Attended Injured Officer
1. Date of First Visit
(month, date, year)
2. Nature of Injury
3. Date of
Hospitalization
5. Type and Frequency of Treatment
6. In Your Opinion Was Disability A Result of the Injury Described In Item 7. Of the Statement of the Injured Officer?
If No, State Your Reason for Believing Officer's Disability Resulted from Other Circumstances
7. Type of Further Treatment Recommended
8. Signature
10. Date Signed
9. Mailing Address Including ZIP Code
Form CA-721a
Rev. Mar 2017
AM PM
Yes
No
Yes
No
If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or
modifications, please contact OWCP. See instructions for additional details.
Print
Reset
Page 2 of 6
Employing Organization's Report
1. Name and Mailing Address Including ZIP Code of Employing
Organization
2. Name of Injury Officer's Immediate Superior
3. Name and Telephone Number of Person to Contact
4. Last, First, Middle Name of Injury Officer 5. Officer's Birth Date (month, day, year) 6. Social Security Number
7. Date Employing Organization First Received Injury Notice 8. Name of Person to Whom Notice Was First Given
9. Date and Hour of Injury 10. Date and Hour Stopped Work 11. Date and Hour Pay Stopped 12. Date and Hour Returned to Work
13. Will Officer Receive Pay For
Any Portion of Absence From
Work Because of the Injury?
If yes, furnish
g
A. Types(s) of Leave B. Amount Paid C. Dates For Which Leave Paid
14. Rate of Pay on Date of injury
15. List and Show Value of Other Pay Increments on Date of Injury
16. On Day of Injury
Officer's Shift
g
A. Began B. Ended 17. Number of Hours
Worked Per Day
(exclusive of overtime)
18. Circle Days Normally Worked Per Week
(exclusive of overtime)
19. Did Officer Work for the Organization a Full 11 Months Immediately
Prior to Injury?
20. If No, Would His Job Have Afforded Employment For 11 Months
Except For the Injury?
21. Was Officer Performing Regular Duties When Injured?
If No, Give Full Explanation
22. Was the Injury Caused By:
23. If Known, Give Name and Address of Suspect(s) or Witness(es) With Whom Officer Was Involved When Injured.
24. Describe Fully How the Officer's Injury Occurred While Enforcing the Laws of the United States. If possible, give U.S. Code Citation.
25. Give Comments Regarding Completeness and Validity of the Facts Provided by Officer (attach detailed explanation if there is disagreement).
26. Signature 27. Title 28. Date Signed
Base
Subsistence, If Extra
Quarter, If Extra
$
$
$
Per
Per
Per
Per
$
$
Per
SU
MO TU
WE
TH FR SA
AM PM
Yes No
AM PM AM PM AM PM
Yes
No
AM PM
AM
PM
Yes No Yes No
Yes No
Yes No
Yes No
Yes No
Form CA-721a
Rev. Mar 2017
Page 3 of 6
5. Has Any Pay Been Claimed or Received for the Period Shown in Item 4?
If Yes, State Amount and List Dates
4. Period Compensation is Claimed as a Result of Pay
Loss:
Claim for Compensation
1. Last, First, Middle Name of Injured Officer 2. Date of Injury (month, day, year)
3. Name of Employing Organization
6. Was Subsistence or Quarters Furnished During Period Shown in
Item 4?
If Yes, State Which and Show Value and
inclusive Period
7. Did Officer Work For Any
Other Employer During
Period Shown in Item 4?
If yes, furnish
g
A. Name and Address of Employer B. Amount Earned C. Period Worked:
8. Has Claim Been Made Against Any
Third Party For Damages on
Account of This Injury?
If yes, furnish
g
A. Name and Address of Party B. Amount of Recovery Received
9. Was Officer Ever in the Armed
Forces of the United States?
If yes, furnish
g
A. Service Number B. Branch of Service C. Period of Service
10. If Question 9 is Answered ''Yes''
Has Application Ever Been Made
for Compensation or Pension,
Including Retirement or Retainer
Pay, on Account of Such Service?
If yes, furnish
g
A. Claim Number B. Name and Address of Office Where Claim is Filed C. Nature of Disability and
Amount of Monthly
Payment
11. Has Application Ever Been Made
for Any Annuity on Account of
Officer's Civilian Service With the
United States?
If yes, furnish
g
A. Type of Annuity (e.g., civil service retirement) B. Claim Number
12. Has Application Been Made For Compensation, Annuity, or Other Benefits as a Result of This Injury Under Any
Compensation Law, Police Disability Compensation Fund, or Other Such Fund?
If Yes, Give Name and Address of Organization With Which Application Was Filed.
13. If Married, Give Date of
Officer's Marriage
14. List Officer's Dependents. If None. So State
15. For Dependents Not Living With Officer, Show Amounts That He Pays for Their Support, to Whom Paid, and Payee's Address. State Whether
Such Payments Were Ordered by A Court.
Form CA-721b
Rev. Mar 2017
From Through
Yes No
Yes No
From
Through
Yes No
Yes No
Yes No
Yes No
Yes No
From
Through
Yes No
Name
Relationship
To Office Date of Birth
Living with Officer?
Yes No If Not, Show Mailing Address
Page 4 of 6
STATEMENT BY EMPLOYING ORGANIZATION: We
hereby certify that the officer who executed the foregoing
claim for compensation was injured while in performance of
duty under 5 U.S.C. 8101 et seq. as extended by 5 U.S.C.
8191. All statements made in this claim are true to the best
of our knowledge and belief.
19. Signature
21. Title
20. Date Signed
Form CA-721b
Rev. Mar 2017
16. Name of Financial Institution for Depositing Benefits:
Checking Savings
17. Account Number: 18. Routing or Transit Number:
Page 5 of 6
INSTRUCTIONS FOR COMPLETING THIS FORM
(Please do not detach)
1. GENERAL. This form is used to report an injury or
occupational disease sustained by a non-Federal law
enforcement officer under circumstances involving a crime
against the United States. Specifically, section 8191 of title 5,
United States Code, provides Federal workmen's compensation
benefits for a person determined to have been on any given
occasion-
(1) a law enforcement officer and to have been engaged on
that occasion in the apprehension or attempted
apprehension of any person-
(A) for the commission of a crime against the United
States, or
(B) who at that time was sought by a law enforcement
authority of the United States for the commission of a
crime against the United States, or
(C) who at that time was sought as a material witness in
a criminal proceeding instituted by the United States: or
(2) a law enforcement officer and to have been engaged on
that occasion in protecting or guarding a person held for the
commission of a crime against the United States or as a
material witness in connection with such a crime; or
(3) a law enforcement officer and to have been engaged on
that occasion in the lawful prevention of, or lawful attempt to
prevent, the commission of a crime against the United
States;
and to have sustained a personal injury (including disease)
related to that occasion. Federal law enforcement officers are
excluded from section 8191.
If one of the above conditions is met, this form should be filed
with the Office of Workers' Compensation Programs if the
injured officer
(1) is disabled and is in a, non-pay status for more than 3
calendar days;
(2) has permanent disability;
(3) is unable to resume his regular work;
(4) incurs unpaid medical expenses; or
(5) if there is a likelihood that disability or unpaid medical
expenses will subsequently occur.
The form is designed so that the CLAIM FOR COMPENSATION
page may be detached if the claim is not needed. However, read
paragraph 6 below thoroughly before detaching the claim page.
If additional space is needed for any answer, attach a separate
sheet of paper and write, ''see separate sheet,'' in the
appropriate box of this form. Please place the name of the
injured officer (and, case file number if known) on any separate
sheets. This form must be filed with OWCP within 5 years from
the date of injury.
2. STATEMENT OF INJURED OFFICER. This statement must
be completed in all instances and only by-
(1) the injured officer, preferably
(2) a member of his immediate family;
(3) his guardian, personal representative, or other person
legally authorized to act on his behalf; or
(4) any association of law enforcement officers acting on his
behalf.
3. STATEMENT OF WITNESS. This statement normally is used
if the injury was not reported at the time that it occurred or if
some fact is not clear. It is not necessary if a report of
investigation is submitted.
4. MEDICAL REPORT BY PHYSICIAN WHO FIRST ATTENDED
INJURED OFFICER. This report is not necessary if a more
complete medical report on this form or on another form or in
narrative is being submitted.
5. EMPLOYING ORGANIZATION'S REPORT. This report must
be completed in every instance. Wage information, duty hours,
and like information should be obtained from the organization's
records. The organization must review the injured officer's
statement and the circumstances of the injury, and in item 25
should comment concerning the completeness and validity of
the officer's statement, If the organization disagrees with the
officer's statement, it should submit a detailed explanation giving
the reasons for its disagreement.
6. CLAIM FOR COMPENSATION. This claim must be completed
in every instance where the injured officer-
(1 ) is disabled and is in a non-pay status for more than 3
calendar days;
(2) has permanent disability; or
(3) is unable to resume his regular work.
It need not be submitted where claim is made only for medical
expenses, or if there is only a likelihood that disability or medical
expense subsequently will occur.
7. DIRECT DEPOSIT INFORMATION. The Department of Treasury
requires all Federal payments be made by electronic funds transfer (EFT),
also called Direct Deposit. You may submit a completed SF-1199A, Direct
Deposit Sign Up, or complete the information in items 16 through 18 of
this form. If you do not have a bank account, you may be required to
receive your payment through Direct Express Debit MasterCard. To
request information on the Direct Express Debit MasterCard, go to
www.usdirectexpress.com or call 1-800-333-1795. If directed to enroll in
the Program, you may contact for the Department of Treasury at
1-888-224-2950 to address any questions or concerns you may have, as
well as apply for a waiver from the process. NOTE: payments to residents
of foreign countries are exempt from the Treasury requirement.
Form CA-721
Rev. Mar 2017
Page 6 of 6
The Office of Workers' Compensation Programs requires this claim before
compensation can be awarded to an officer for pay loss, permanent
disability, or when the Officer is unable to resume his regular work. The
officer completes items 1 through 18 and gives it to the officer's employing
organization which will certify as to the validity of the information
contained in the claim by completing items 19, 20, and 21. If it does not
agree that all answers are correct, it should attach a detailed statement
giving the reason for its disagreement. If pay loss is involved, this claim
should not be completed until 14 calendar days have elapsed since the
beginning of the pay loss, or until the officer has returned to work,
whichever occurs first.
8. ATTENDING PHYSICIAN'S MEDICAL REPORT. If the CLAIM FOR
COMPENSATION is completed, this report is to be completed by the
physician supervising medical treatment. It is not necessary if the CLAIM
FOR COMPENSATION is not completed.
9. SUBMITTING THIS FORM. This form should be turned over to the
employing organization. The organization will have any remaining parts
completed. Afterwards, it should review the form for completeness and to
see that all signatures appear. If a report of investigation of any type was
made on the injury or the incident leading to injury, a copy should be
attached. When the form and any statements and attachments are ready
for transmission, this instruction page should be removed. Only one copy
of this form (the original) need be submitted.
Privacy Act
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Federal
Employees' Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.) (FECA) is administered by the Office of
Workers Compensation Programs of the U.S. Department of Labor, which receives and maintains personal information on
claimants and their immediate families. (2) Information which the Office has will be used to determine eligibility for and the amount
of benefits payable under the FECA, and may be verified through computer matches or other appropriate means. (3) Information
may be given to the Federal agency which employed the claimant at the time of injury in order to verify statements made, answer
questions concerning the status of the claim, verify billing, and to consider issues relating to retention, rehire, or other relevant
matters. (4) Information may also be given to other Federal agencies, other government entities, and to private-sector agencies
and/or employers as part of rehabilitative and other return-to-work programs and services. (5) Information may be disclosed to
physicians and other health care providers for use in providing treatment or medical/vocational rehabilitation, making evaluations
for the Office, and for other purposes related to the medical management of the claim. (6) Information may be given to Federal,
state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the FECA, to determine
whether benefits are being paid properly, including whether prohibited dual payments are being made, and, where appropriate, to
pursue salary/administrative offset and debt collection actions required or permitted by the FECA and/or the Debt Collection Act.
(7) Disclosure of the claimant's social security number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN
and/or TIN, and other information maintained by the Office, may be used for identification, to support debt collection efforts
carried on by the Federal government, and for other purposes required or authorized by law. (8) Completion of this form is
voluntary; however, failure to disclose all requested information may delay the processing of the claim or the payment of benefits,
or may result in an unfavorable decision or reduced level of benefits.
Note: This notice applies to all forms requesting information that you might receive from the Office in connection
with the processing and adjudication of the claim you filed under the FECA.
THIS NOTICE SHOULD BE RETAINED FOR YOUR INFORMATION.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such
collection displays a valid OMB control number. Public reporting burden for this collection of this information is estimated to
average 60 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the date needed, and completing and reviewing the collection of information. The authority for requesting this
information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits. Furnishing the requested
information is required for the claimant to obtain or retain a benefit. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the U. S. Department of Labor, OWCP,
Room S3229, 200 Constitution Avenue, NW, Washington, DC 20210, and reference OMB Control Number 1240-0022. DO NOT
SEND THE COMPLETED FORM TO THIS ADDRESS.
All completed forms, documents, and inquiries should be sent to
OWCP, Dist Office 9, Cleveland
1240 East Ninth Street, Room 851
Cleveland, Ohio 44199
Request for Accommodations or Auxiliary Aids and Services
If you have a disability, federal law gives you the right to receive help from the OWCP in the form of communication assistance,
accommodation(s) and/or modification(s) to aid you in the claims process. For example, we will provide you with copies of
documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or
changes to accommodate your disability. Please contact our office or your OWCP claims examiner to ask about this assistance.
Form CA-721
Rev. Mar 2017
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Notice of Law Enforcement Officer's Injury Or Occupational (Department of Labor)

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Completed 19 July 2020

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