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OMB Control No: 1240-0022	ICR Reference No: 202607-1240-002
Status: Received in OIRA	Previous ICR Reference No: 202410-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 09/29/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	4	2
Time Burden (Hours)	5	3
Cost Burden (Dollars)	3	3

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	4	2	2
Annual Time Burden (Hours)	5	3	2
Annual Cost Burden (Dollars)	3	3	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Respondents: The number of respondents increased from 2 to 4. This increase in respondents was due to more forms being received. Responses: The number of responses increased from 2 to 4 due to an increase in respondents. Burden Hours: The total number of burden hours increased from 0.3333 hours to 1.333 hours due to the increase in respondents. Costs to Respondents or Recordkeepers: No change. The prior SS showed $1.00. However, the prior ROCIS entry showed $3.00 which is the same as this ICR extension. The number of these claims will remain low as jurisdictions are using less non-federal law enforcement officers to assist in circumstances involving a crime against the United States.

Annual Cost to Federal Government: $71

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Pamela Hamai 415 241-3350 hamai.pamela@dol.gov

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