Official Federal Forms > US Dept Of Labor
Notice Of Law Enforcement Officers Death CA-722 - Official Federal Forms
| Notice Of Law Enforcement Officers Death Form. This is a national form and can be used in US Dept Of Labor . |
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Notice of Law Enforcement Officers U.S. Department of Labor Employment Standards Administration Death Office of Workers Compensation Programs Note: Persons are not required to respond to this collection of informat ion unless it displays a currently OMB No. 1215-0116valid OMB control number. Expires: 08-31-2007 EMPLOYING ORGANIZATIONS REPORT 1. Name and Mailing Address Including ZIP Code of 2. Name of Deceased Officers Immediate Superior Employing Organization 3. Name and Telephone Number of Person to Contact 4. Last, First, Middle Name of Deceased Officer 5. Officers Birth Date 6. Social Security Number (month, day, year) 7. Officers Last Mailing Address Including ZIP Code 8. Date and Hour of Injury 9. Date of Death 10. Date and Hour Pay Stopped am/ am/ pm pm 11. Rate of Pay on Date of Injury 12. List and Show Value of Other Pay Increments on Date of injury Base Per $ Subsistence, If Extra $ Per $ Per Quarters, If Extra $ Per $ Per 13. On Day of Injury a. Began b. Ended 14. Number of Hours 15. Circle Days Normally Officers Shift Worked Per Day (exclusive Worked Per Week (exclusive am/ am/ pm pm of overtime) of overtime)SU MO TU WE TH FR SA16. Did Officer Work for the Organization a Full 11 17. If No, Would His Job Have Afforded Employment Months Immediately Prior to Injury? For 11 Months Except For the Injury? Yes No Yes No 18. Describe Nature of Injury Which Caused Death 19. Describe Fully How the Officers Death Occurred While Enforcing the Laws of the United States. If possible, give the U.S. Code Citation.20. Was Officer Performing Regular Duties When Injured? If No, Give Full ExplanationYes No 21. Was the Injury Caused By: a. Officers Willful Misconduct? Yes No b. Officers intoxication? Yes No c. Officers Intent to Bring About Injury to Self or Another (other tha n normally required in performance of duty)?Yes No Attach Detailed Explanation for Any Yes Answers 22. If Known, Give Name and Address of Suspect(s) or Witness(es) Wit h Whom Officer Was Involved When Injured 23. Has Application Been Made for Compensation, Annuity, or Other Benefi ts as a Result of This Death Under Any Compensation Law, Police Death or Survivors Benefit Fund, or Other Such Fund? Yes No If Yes, Give Name and Address of Organization With Which Application Was Filed. Form CA-722a Rev. Oct 2001<<<<<<<<<********>>>>>>>>>>>>> 224. Define, Explain, or Identify the Circumstances of This Injury Resulting in Death Which Involves the United States (see the first paragraph of the instruction sheet attached to this form). 25. Signature 26. Date Signed We hereby certify that the officer, whose death is reported above, 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 27. Title report are true to the best of our knowledge and belief. IMPORTANT: Please attach a copy of any investigation report of this injury and death. If no report was made, a statement from each witness should be attached reporting what he saw, heard, or knows about the incident leading to injury and death. ATTENDING PHYSICIANS MEDICAL REPORT 1. Last, First, Middle Name of Deceased Officer 2. Date of Death (month, day, year)3. History of Injury 4. If Death Was Not Instantaneous, Describe Treatment Provided 5. Inclusive Dates on Which Treatment Was Given6. Direct Cause of Death 7. Contributory Cause of Death 8. In Your Opinion, Was Death of the Officer Due to the Injury as Reported in Item 3? Yes No If No, State Your Reasons For Believing Death Resulted From Other Causes. 9. Was a Biopsy or Autopsy Performed? Yes No If So, By Whom? 10. I certify that the answers to the above questions 11. Signature 12. Date Signed are true to the best of my knowledge and belief. I am licensed to practice medicine and surgery in the state of 13. Mailing Address Including ZIP Code Public Burden Statement Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers Compensation Programs, Room S3229, 200 Constitution Avenue, N.W., Washington, DC. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE. <<<<<<<<<********>>>>>>>>>>>>> 3 INSTRUCTIONS FOR COMPLETING THIS FORM (Please do not detach) 1. GENERAL. This form is used to report a death sustained by a 3. ATTENDING PHYSICIANS MEDICAL REPORT. This report is tonon-Federal law enforcement officer under circumstances involving be completed by a physician who examined or treated the deceaseda crime against the United States. Specifically, section 8191 of titleofficer. It is not necessary if a copy of a more complete medical report5, United States Code, provides Federal workmens compensation is being submitted. benefits for a person determined to have been on any given occasion - 4. CLAIM ON BEHALF OF WIDOW, WIDOWER, OR CHILDREN. This (1) a law enforcement officer and to have been engaged on is a formal claim for death benefits on behalf of all those listed in the that occasion in the apprehension or attempted apprehension claim, it may be submitted by - of any person (A) for the commission of a crime against the United (1) any survivor of the deceased officer; States, or (2) any guardian, personal representative, or other person legally (B) who at that time was sought by a law enforcement authorized to act on behalf of the officers estate or any of his authority of the United States for the commission of a survivors; or crime against the United States, or (3) any association of law enforcement officers acting on behalf (C) who at that time was sought as a material witness in a of the officers survivors. criminal proceeding instituted by the United States; or (2) a law enforcement officer and to have been engaged on Items 6 through 11 on this claim pertain to the surviving spouse and that occasion in protecting or guarding a person held for the should not be completed if no claim is being made on his or her commission of a crime against the United States or as a behalf, or if there is no surviving spouse. Item 12 asks for names of material witness in connection with such a crime; or surviving children. If there are more child
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