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This document announces the submission of public information collection requests to the Office of Management and Budget (OMB) for review and approval under the Paperwork Reduction Act, specifically
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How to fill out Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA–721), Notice of Law Enforcement Officer’s Death (CA–722)
01
Obtain the CA–721 or CA–722 form from your agency or the appropriate website.
02
Fill out the identifying information for the officer involved, including name, badge number, and department.
03
For CA–721, detail the nature of the injury or occupational disease, including the date and location of the incident.
04
For CA–722, provide information regarding the circumstances of the officer's death, including the date, time, and cause of death.
05
Document any witnesses and their contact information, if applicable.
06
Include any medical treatment received for CA–721 or relevant details regarding the officer's passing for CA–722.
07
Review all information for accuracy and completeness before submitting.
08
Submit the completed form to the appropriate authority within your agency, typically the personnel or human resource division.
Who needs Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA–721), Notice of Law Enforcement Officer’s Death (CA–722)?
01
Law enforcement officers who have sustained injuries or been diagnosed with occupational diseases.
02
Families or representatives of law enforcement officers who have died in the line of duty.
03
Departmental administrators who need to process workers' compensation claims or manage line-of-duty death benefits.
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People Also Ask about
Can you sue a police officer for injury?
If you believe you've been harmed due to police misconduct or negligence, you may be considering suing the police department for negligence in California. The answer is yes—you can pursue legal action under certain circumstances.
Is assaulting a police officer a felony in California?
Found within California Labor Code § 3213.2, the duty-belt presumption is a workers' compensation policy in our state that makes it easier for police officers to qualify for benefits for a lower back injury.
What are presumptive injuries for police officers in California?
The OWCP Form CA-35, titled “Evidence Required in Support of a Claim for Occupational Disease,” is used to gather documentation and information to support a claim for benefits under the Federal Employees' Compensation Act (FECA) due to an occupational disease.
What is a presumptive injury?
Presumptive injuries are encompassed within Labor Code Section 3212 and 3213 and include conditions such as heart trouble, pneumonia, hernias (including hiatal hernias that cause gastrointestinal symptoms), cancer, tuberculosis, back trouble (peace officers only), MRSA and diseases caused by bloodborne pathogens.
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What is Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA–721), Notice of Law Enforcement Officer’s Death (CA–722)?
The Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA–721) is a form used to report injuries or occupational diseases incurred by law enforcement officers. The Notice of Law Enforcement Officer’s Death (CA–722) is used to report the death of a law enforcement officer resulting from a job-related incident.
Who is required to file Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA–721), Notice of Law Enforcement Officer’s Death (CA–722)?
Typically, the employer or the authorized representative of the law enforcement officer is required to file these notices. In some cases, the officer themselves or their family may also file the notice, particularly in the event of death.
How to fill out Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA–721), Notice of Law Enforcement Officer’s Death (CA–722)?
To fill out the CA–721, provide the officer's personal information, details about the injury or disease, dates, and circumstances. For the CA–722, similar information is required along with details concerning the officer’s death and any contributing factors.
What is the purpose of Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA–721), Notice of Law Enforcement Officer’s Death (CA–722)?
The purpose of these notices is to formally document injuries, occupational diseases, or deaths of law enforcement officers, which is essential for ensuring that affected individuals receive appropriate workers' compensation benefits and support.
What information must be reported on Notice of Law Enforcement Officer’s Injury or Occupational Disease (CA–721), Notice of Law Enforcement Officer’s Death (CA–722)?
Required information includes the officer's name, address, date of birth, date of the incident, description of the injury or disease, details about the working conditions, and any relevant witness information. For the CA–722, additional details about the circumstances of the death must also be reported.
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