Form CA-721A "Notice of Law Enforcement Officer's Injury or Occupational Disease"

What Is Form CA-721A?

This is a legal form that was released by the U.S. Department of Labor - Office of Workers' Compensation Programs on March 1, 2017 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest available edition released by the U.S. Department of Labor - Office of Workers' Compensation Programs;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CA-721A by clicking the link below or browse more documents and templates provided by the U.S. Department of Labor - Office of Workers' Compensation Programs.

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Notice of Law Enforcement Officer's
U.S. Department of Labor
Print
Reset
Injury Or Occupational Disease
Office of Workers' Compensation Programs
Note: Persons are not required to respond to this collection of information unless it displays a currently
OMB No. 1240-0022
valid OMB number.
Expires: 04/30/2020
Statement of Injured Officer
1. Last, First, Middle Name of Injured Officer
2. Date of Injury (month, day, year)
3. Hour of Injury
4. Location Where Injury Occurred (number, street, building, city, state)
AM
PM
5. Nature of Injury (e.g., fractured left leg)
6. Did Injury Cause Permanent Disability?
Yes
No
If Yes, Describe
7. Describe Fully Why and How Injury Occurred
I certify that the injury described above was
8. Signature
9. Date Signed
sustained in performance of official duty and
occurred in such a manner as to entitle me to
10. Mailing Address Including ZIP Code
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.
Statement of Witness
1. Describe What You Saw, Heard or Know About This Injury
2. Signature
3. Date Signed
Medical Report by Physician who First Attended Injured Officer
1. Date of First Visit
2. Nature of Injury
(month, date, year)
3. Date of
4. Name and Mailing Address of Hospital
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
Yes
No
7. Type of Further Treatment Recommended
8. Signature
9. Mailing Address Including ZIP Code
10. Date Signed
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.
Form CA-721a
Rev. Mar 2017
Page 1 of 6
Notice of Law Enforcement Officer's
U.S. Department of Labor
Print
Reset
Injury Or Occupational Disease
Office of Workers' Compensation Programs
Note: Persons are not required to respond to this collection of information unless it displays a currently
OMB No. 1240-0022
valid OMB number.
Expires: 04/30/2020
Statement of Injured Officer
1. Last, First, Middle Name of Injured Officer
2. Date of Injury (month, day, year)
3. Hour of Injury
4. Location Where Injury Occurred (number, street, building, city, state)
AM
PM
5. Nature of Injury (e.g., fractured left leg)
6. Did Injury Cause Permanent Disability?
Yes
No
If Yes, Describe
7. Describe Fully Why and How Injury Occurred
I certify that the injury described above was
8. Signature
9. Date Signed
sustained in performance of official duty and
occurred in such a manner as to entitle me to
10. Mailing Address Including ZIP Code
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.
Statement of Witness
1. Describe What You Saw, Heard or Know About This Injury
2. Signature
3. Date Signed
Medical Report by Physician who First Attended Injured Officer
1. Date of First Visit
2. Nature of Injury
(month, date, year)
3. Date of
4. Name and Mailing Address of Hospital
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
Yes
No
7. Type of Further Treatment Recommended
8. Signature
9. Mailing Address Including ZIP Code
10. Date Signed
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.
Form CA-721a
Rev. Mar 2017
Page 1 of 6
Employing Organization's Report
1. Name and Mailing Address Including ZIP Code of Employing
2. Name of Injury Officer's Immediate Superior
Organization
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
Yes
No
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
AM
PM
AM
PM
AM
PM
AM
PM
13. Will Officer Receive Pay For
A. Types(s) of Leave
B. Amount Paid
C. Dates For Which Leave Paid
Any Portion of Absence From
Work Because of the Injury?
g
Yes
If yes, furnish
No
14. Rate of Pay on Date of injury
15. List and Show Value of Other Pay Increments on Date of Injury
Base
$
Per
$
Per
Subsistence, If Extra
$
Per
$
Per
Quarter, If Extra
$
Per
16. On Day of Injury
A. Began
B. Ended
17. Number of Hours
18. Circle Days Normally Worked Per Week
Officer's Shift
Worked Per Day
(exclusive of overtime)
g
(exclusive of overtime)
SU
MO
TU
WE
TH
FR
SA
AM
PM
AM
PM
19. Did Officer Work for the Organization a Full 11 Months Immediately
20. If No, Would His Job Have Afforded Employment For 11 Months
Yes
No
Yes
No
Prior to Injury?
Except For the Injury?
21. Was Officer Performing Regular Duties When Injured?
Yes
No
If No, Give Full Explanation
22. Was the Injury Caused By:
a. Officer's Willful Misconduct?
Yes
No
b. Officer's Intoxication?
Yes
No
Yes
No
c. Officer's Intent to Bring About Injury to Self or Another (other than normally required in performance of duty)?
Attach Detailed Explanation for Any ''Yes'' Answers
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
Form CA-721a
Rev. Mar 2017
Page 2 of 6
Claim for Compensation
1. Last, First, Middle Name of Injured Officer
2. Date of Injury (month, day, year)
3. Name of Employing Organization
4. Period Compensation is Claimed as a Result of Pay
Loss:
From
Through
5. Has Any Pay Been Claimed or Received for the Period Shown in Item 4?
6. Was Subsistence or Quarters Furnished During Period Shown in
Item 4?
Yes
No
If Yes, State Amount and List Dates
If Yes, State Which and Show Value and
Yes
No
inclusive Period
7. Did Officer Work For Any
A. Name and Address of Employer
B. Amount Earned
C. Period Worked:
Other Employer During
From
Period Shown in Item 4?
g
Through
If yes, furnish
Yes
No
8. Has Claim Been Made Against Any
A. Name and Address of Party
B. Amount of Recovery Received
Third Party For Damages on
Account of This Injury?
g
If yes, furnish
Yes
No
9. Was Officer Ever in the Armed
A. Service Number
B. Branch of Service
C. Period of Service
Forces of the United States?
From
g
If yes, furnish
Through
Yes
No
10. If Question 9 is Answered ''Yes''
A. Claim Number
B. Name and Address of Office Where Claim is Filed
C. Nature of Disability and
Has Application Ever Been Made
Amount of Monthly
for Compensation or Pension,
Payment
Including Retirement or Retainer
Pay, on Account of Such Service?
g
If yes, furnish
Yes
No
11. Has Application Ever Been Made
A. Type of Annuity (e.g., civil service retirement)
B. Claim Number
for Any Annuity on Account of
Officer's Civilian Service With the
United States?
g
If yes, furnish
Yes
No
12. Has Application Been Made For Compensation, Annuity, or Other Benefits as a Result of This Injury Under Any
13. If Married, Give Date of
Compensation Law, Police Disability Compensation Fund, or Other Such Fund?
Officer's Marriage
If Yes, Give Name and Address of Organization With Which Application Was Filed.
Yes
No
14. List Officer's Dependents. If None. So State
Relationship
Living with Officer?
Name
To Office
Date of Birth
Yes
No
If Not, Show Mailing Address
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
Page 3 of 6
Checking
Savings
16. Name of Financial Institution for Depositing Benefits:
17. Account Number:
18. Routing or Transit Number:
STATEMENT BY EMPLOYING ORGANIZATION: We
19. Signature
20. Date Signed
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.
21. Title
8191. All statements made in this claim are true to the best
of our knowledge and belief.
Form CA-721b
Rev. Mar 2017
Page 4 of 6
INSTRUCTIONS FOR COMPLETING THIS FORM
(Please do not detach)
1. GENERAL. This form is used to report an injury or
2. STATEMENT OF INJURED OFFICER. This statement must
occupational disease sustained by a non-Federal law
be completed in all instances and only by-
enforcement officer under circumstances involving a crime
against the United States. Specifically, section 8191 of title 5,
(1) the injured officer, preferably
United States Code, provides Federal workmen's compensation
benefits for a person determined to have been on any given
(2) a member of his immediate family;
occasion-
(3) his guardian, personal representative, or other person
(1) a law enforcement officer and to have been engaged on
legally authorized to act on his behalf; or
that occasion in the apprehension or attempted
apprehension of any person-
(4) any association of law enforcement officers acting on his
behalf.
(A) for the commission of a crime against the United
States, or
3. STATEMENT OF WITNESS. This statement normally is used
if the injury was not reported at the time that it occurred or if
(B) who at that time was sought by a law enforcement
some fact is not clear. It is not necessary if a report of
authority of the United States for the commission of a
investigation is submitted.
crime against the United States, or
4. MEDICAL REPORT BY PHYSICIAN WHO FIRST ATTENDED
(C) who at that time was sought as a material witness in
INJURED OFFICER. This report is not necessary if a more
a criminal proceeding instituted by the United States: or
complete medical report on this form or on another form or in
narrative is being submitted.
(2) a law enforcement officer and to have been engaged on
that occasion in protecting or guarding a person held for the
5. EMPLOYING ORGANIZATION'S REPORT. This report must
commission of a crime against the United States or as a
be completed in every instance. Wage information, duty hours,
material witness in connection with such a crime; or
and like information should be obtained from the organization's
records. The organization must review the injured officer's
(3) a law enforcement officer and to have been engaged on
statement and the circumstances of the injury, and in item 25
that occasion in the lawful prevention of, or lawful attempt to
should comment concerning the completeness and validity of
prevent, the commission of a crime against the United
the officer's statement, If the organization disagrees with the
States;
officer's statement, it should submit a detailed explanation giving
the reasons for its disagreement.
and to have sustained a personal injury (including disease)
related to that occasion. Federal law enforcement officers are
6. CLAIM FOR COMPENSATION. This claim must be completed
excluded from section 8191.
in every instance where the injured officer-
If one of the above conditions is met, this form should be filed
(1 ) is disabled and is in a non-pay status for more than 3
with the Office of Workers' Compensation Programs if the
calendar days;
injured officer
(2) has permanent disability; or
(1) is disabled and is in a, non-pay status for more than 3
calendar days;
(3) is unable to resume his regular work.
(2) has permanent disability;
It need not be submitted where claim is made only for medical
expenses, or if there is only a likelihood that disability or medical
(3) is unable to resume his regular work;
expense subsequently will occur.
(4) incurs unpaid medical expenses; or
7. DIRECT DEPOSIT INFORMATION. The Department of Treasury
requires all Federal payments be made by electronic funds transfer (EFT),
(5) if there is a likelihood that disability or unpaid medical
also called Direct Deposit. You may submit a completed SF-1199A, Direct
expenses will subsequently occur.
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
The form is designed so that the CLAIM FOR COMPENSATION
receive your payment through Direct Express Debit MasterCard. To
page may be detached if the claim is not needed. However, read
request information on the Direct Express Debit MasterCard, go to
paragraph 6 below thoroughly before detaching the claim page.
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
If additional space is needed for any answer, attach a separate
1-888-224-2950 to address any questions or concerns you may have, as
sheet of paper and write, ''see separate sheet,'' in the
well as apply for a waiver from the process. NOTE: payments to residents
appropriate box of this form. Please place the name of the
of foreign countries are exempt from the Treasury requirement.
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.
Form CA-721
Rev. Mar 2017
Page 5 of 6
Page of 6