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Notice Of Law Enforcement Officers Injury Or Occupational Disease CA-721 - Official Federal Forms
| Notice Of Law Enforcement Officers Injury Or Occupational Disease 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 Injury Or Occupational Disease 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 number. Expires: 08-31-2007Statement 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, stat e) am pm 5. Nature of Injury (e.g., fractured left leg) 6. Did Injury Cause Permanent Disability? Yes No If Yes, Describe 7. Described 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 benefits under 5 U.S.C. 8101 et seq. as extended by 5 U.S.C. 8191. I hereby make 10. Mailing Address Including ZIP Code 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, day, year) 3. Dates of Hospitalization 4. Name and Mailing Address of Hospital 5. Type and Frequency of Treatment 6. In Your Opinion Was Disability A Result of the Injury Described In It em 7. Of the Statement of the Injured Officer? Yes No If No, State Your Reason for Believing Officers Disability Resulted fro m Other Circumstances 7. Type of Further Treatment Recommended 8. Signature 9. Mailing Address Including ZIP Code 10. Date Signed Form CA-721a Rev. Oct 2001<<<<<<<<<********>>>>>>>>>>>>> 2The Office of Workers Compensation Programs requires this 7. ATTENDING PHYSICIANS MEDICAL REPORT. If theclaim before compensation can be awarded to an officer for payCLAIM FOR COMPENSATION is completed, this report is to beloss, permanent disability, or when the Officer is unable to completed by the physician supervising medical treatment. It isresume his regular work. The officer completes items 1 throughnot necessary if the CLAIM FOR COMPENSATION is not15 and gives it to the officers employing organization which willcompleted.certify as to the validity of the information contained in the claim 8. SUBMITTING THIS FORM. This form should be turned overby completing items 17, 18, and 19. If it does not agree that allto the employing organization. The organization will have anyanswers are correct, it should attach a detailed statement givingremaining parts completed. Afterwards, it should review the formthe reason for its disagreement. If pay loss is involved, this claimfor completeness and to see that all signatures appear. If ashould not be completed until 14 calendar days have elapsed report of investigation of any type was made on the injury or thesince the beginning of the pay loss, or until the officer has incident leading to injury, a copy should be attached. When thereturned to work, whichever occurs first. 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. 522a), 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 claimants 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) 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 StatementPublic reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewinginstructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collectionof information. Send comments regarding this burden estimate or any other aspect of this collection of information, includingsuggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers Compensation Programs, Room S3229, 200Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM T
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