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 userra@osd.mil or call 1-800-336-4590 and choose option one.

Service Member Information

* First * This is a required field.

* Last * This is a required field.

Address

* City * This is a required field.

Apt/Suite

* State ZIP
* State & Zip are required fields.
* State & Zip are required fields.

* Email * This is a required field. * Invalid email address

* Phone * This is a required field.

Alt. Phone

Fax

Uniformed Service Information

* Serve(d) in * This is a required field.

* Military Pay Grade * This is a required field.

Unit Name

Unit Phone

Unit Address

Unit POC

* Currently on military duty for extended period? * This is a required field.

Employer Information

* Employer Name * This is a required field.

* Employer Type * This is a required field.

Address

* City * This is a required field.

Zip

Apt/Suite

* State/Territory/APO/FPO * This is a required field.

* Contact Name * This is a required field.

* Contact Phone * This is a required field.

Privacy Act Statement

"Authority: 38 U.S.C. Chapter 43, Employment and Reemployment Rights of Members of the Uniformed Services (USERRA); 5 U.S.C. 571-583, Administrative Dispute Resolution Act (ADRA); 5 U.S.C. 552a, the Privacy Act of 1974; DoD Directive 1250.1, National Committee for Employer Support of the Guard and Reserve; DoD Instruction 1205.22, Employer Support of the Guard and Reserve; DoD Instruction 1205.12, Civilian Employment and Reemployment Rights of Applicants for, and Service Members and Former Service Members of the Uniformed Services.

Purpose: To determine eligibility and nature of services requested for USERRA informational assistance and informal mediation and collect statistical data on USERRA inquiries.

Routine Use(s): To communicate with Military Members and Federal, State, and local governmental agencies, as well as to private employers, to answer USERRA questions and furtherance of informal mediation efforts to resolve employment-reemployment conflicts and collect and report statistical data for annual reports to Congress and appropriate DoD agencies about USERRA support provided.

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

ADRA Notice: Information collect related to ESGR Ombudsman informal mediation may be confidential under 5 U.S.C. 571-583, Administrative Dispute Resolution Act (ADRA) and not releasable without written authorization by all parties involved in the mediation."

* Initials * This is a required field.

Date

Have you officially engaged the Department of Labor or hired a private attorney?

How did you hear about ESGR?

Explain your claim in detail (Who, What, When, Where and Why)

Submit