USERRA Support Request

This form is intended for those who are experiencing civilian employment problems related to military obligations.

ESGR is an agency of the Department of Defense which informally mediates between employers and their Guard and Reserve employees. Disputes between employers and employees are resolved through the efforts of ESGR’s Volunteer Ombudsmen in all 50 states, 4 territories and Europe. The communications made by parties during informal mediation are protected by the Administrative Dispute Resolution Act.

If you believe your rights under USERRA have been violated by your employer, you can call 1-800-336-4590 (option one) between 8am and 6pm Eastern Standard Time to speak with an ESGR representative or you may fill out the form below. An ESGR representative will contact you.

If you have any questions regarding the request and processing, please e-mail us at osd.USERRA@mail.mil or call 1-800-336-4590 and choose option one.

Please note:  If, after 4 days of initial contact, your assigned Ombudsman has not heard from you, your case will be closed.  A new case can be opened when you are available to discuss your concerns with your assigned Ombudsman.

UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) SUPPORT REQUEST


INSTRUCTIONS

This form is intended for members of the Uniformed Services (National Guard, Reserves, and the National Disaster Medical System (NDMS)), who are experiencing civilian employment concerns related to uniformed service obligations.

Employer Support of the Guard and Reserve (ESGR) is an office within the Department of Defense which informally mediates employment concerns between civilian employers and their National Guard, Reserve, and/or NDMS employees. Conflicts involving alleged Uniformed Services Employment and Reemployment Rights Act (USERRA) complaints are mediated through the efforts of ESGR's Volunteer Ombudsmen in all 50 states and 4 territories. The communications made by parties during informal mediation are protected by the Administrative Dispute Resolution Act (5 U.S.C. ??571-583) and may not be released without written authorization by all parties involved in the mediation.

If you believe your rights under USERRA have been violated by your employer, you can call 1-800-336-4590 (option 1) between 8 AM and 6 PM Eastern Time (M-F) to speak with an ESGR representative or you may fill out the form below. An ESGR representative will contact you.

If you have any questions regarding the request and processing, please e-mail us at osd.USERRA@mail.mil or call 1-800-336-4590 (option 1).

Please note: If after 4 days of initial contact, your assigned Ombudsman has not heard from you, your case will be closed. A new case may be opened when you are available to discuss your concerns with your assigned Ombudsman.

Items marked with an asterisk (*) are mandatory.

SERVICE MEMBER INFORMATION

1. DATE SUBMITTED
2. NAME:
         

CURRENT UNIFORMED SERVICE

*3. SERVING IN                                                  *4. PAY GRADE

 
 
*5. EMAIL ADDRESS

   
*6. TELEPHONE NUMBER (Include area code and extension if any)          7. ALTERNATE TELEPHONE NUMBER (Include area code and extension if any)
                                                           
 
*8. STATE                                                                                                               *9. ZIP CODE
                 

EMPLOYER INFORMATION

*10. EMPLOYER NAME
   
*11. EMPLOYER TYPE                               *12. STATE                                                     *13. ZIP CODE
      
     
*14. CONTACT NAME (Last, First, Middle Initial)
   
*15 TELEPHONE NUMBER (Include area code and extension if any)         16. EMAIL ADDRESS:
                                                          
   
*17. HAVE YOU OFFICIALLY ENGAGED THE DEPARTMENT OF LABOR OR HIRED AN ATTORNEY?

 
*18. ARE YOU ON A MILITARY LEAVE OF ABSENCE FROM YOUR CIVILIAN EMPLOYER?

 
19. HOW DID YOU HEAR ABOUT ESGR?
*20. EXPLAIN YOUR CLAIM IN DETAIL (Who, What, When, Where and Why) (Limit 500 characters)
 
You have 500 characters


DD FORM 3022


PRIVACY ACT STATEMENT

"Authority: 38 U.S.C. 43, Employment and Reemployment Rights of Members of the Uniformed Services; 5 U.S.C. 574, Confidentiality; 5 U.S.C. Part I, Chapter 5, Subchapter IV, Alternative Means of Dispute Resolution in the Administrative Process; 42 U.S.C. 300hh-11,National Disaster Medical System, ((d)(3) Employment and reemployment rights); 20 CFR 1002, Regulations Under the Uniformed Services Employment and Reemployment Rights Act of 1994; 5 CFR 353, Restoration to Duty from Uniformed Service or Compensable Injury; DoD Directive 1250.01, National Committee for Employer Support of the Guard and Reserve (NCESGR); DoD Instruction 1205.22, Employer Support of the Guard and Reserve; and DoD Instruction 1205.12, Civilian Employment and Reemployment Rights of Applicants for, and Service Members and Former Service Members of the Uniformed Services.

Principle Purpose(s): To support the ESGR Ombudsman Program by tracking assistance provided to members of the Uniformed Services, to include the National Disaster Medical System; by recording information related to answering inquiries related to the USERRA; and by reporting statistics related to the Ombudsman Program in aggregate and at State committee level. The applicable Privacy Act System of Records Notice is DHRA 16, Inquiry and Case Management System found at http://dpcld.defense.gov/Privacy/SORNs/aspx.

Routine Use(s): Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. To the Department of Labor for Congressionally-mandated USERRA reporting (38 U.S.C. Employment and Reemployment Rights of Members of the Uniformed Services, section 4432, Reports). Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Disclosure When Requesting Information Routine Use, Disclosure of Requested Information Routine Use, Congressional Inquiries, Disclosure to the Office of Personnel Management Routine Use, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use, Disclosure to the Merit Systems Protection Board Routine Use, and Data Breach Remediation Purposes Routine Use. The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices may apply to this system. The complete list of DoD Blanket Routine Uses can be found Online at: http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.

Disclosure: Voluntary; however, failure to provide accurate contact information and other solicited information may delay or prevent ESGR from processing the request.

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