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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.

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: 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; 20 CFR Part 1002, Regulations under the uniformed services employment and reemployment rights act of 1994; 38 U.S.C. Chapter 43, Employment and reemployment rights of members of the uniformed services; 5 CFR part 353, Restoration to duty from uniformed service or compensable injury; 42 U.S.C. 300hh-11, National Disaster Medical System; DoD Instruction 1205.12, Civilian Employment and Reemployment Rights of Applicants for, and Service Members and Former Service Members of the Uniformed Services; 5 U.S.C. 574, Confidentiality; 10 U.S.C. 1588, Authority to accept certain voluntary services; DoD Instruction 1100.21, Voluntary Services in the Department of Defense; ESGR Instruction 1250.10, Volunteer Management; ESGR Instruction 1250.32, Ombudsman Services Program.

Purpose: To support the ESGR Ombudsman Program by tracking assistance provided to members of the Uniformed Service, to include the National Disaster Medical System; by recording information related to the mediation of disputes and answering of inquiries related to the USERRA; by tracking case assignments and mediation results of potential conflicts between employers and the Service members they employ; and by reporting statistics related to the Ombudsman Program in aggregate and at State committee-level.

Routine Use(s): To Department of Labor for USERRA reporting, mandated by Section 4432 of Title 38 United States Code. The DoD Blanket Routine Uses found at: http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx apply to this collection

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