USERRA Information Request DD Form 3021 Webpage

USERRA Information Request.
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USERRA Inquiry

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Employer Support of the Guard and Reserve (ESGR) can assist in
answering anyone's questions related to the Uniformed Services
Employment Reemployment Rights Act (USERRA). ESGR also has
Ombudsmen available to mediate uniformed service related disputes
between service members and their civilian employers.
If you have questions you can call ESGR's toll-free number, 1-800-3364590 (select option 1) between 8 AM and 6 PM EST (M-F); e-mail
[email protected] or complete the form below.
If you are a service member desiring to have an Ombudsman assist
you and your employer resolve a dispute related to your military
service, call ESGR's toll-free number, 1-800-336-4590 (select option 1)
between 8 AM and 6 PM EST (M-F) or submit a USERRA Support
Request.

UNIFORMED SERVICES EMPLOYMENT AND
REEMPLOYMENT RIGHTS ACT (USERRA)
INQUIRY

INSTRUCTIONS
Employer Support of the Guard and Reserve (ESGR) can assist
in answering questions related to the Uniformed Services
Employment and Reemployment Rights Act (USERRA). ESGR
also has ombudsmen available to conduct neutral, informal
mediation for conflicts between Service members and their
civilian employers.
If you have questions you can call ESGR's toll-free number, 1800-336-4590 (select option 1), between 8 AM and 6 PM EST
https://www.esgr.mil/USERRA/USERRA-Contact/USERRA-Information-Request/t/0[10/31/2023 2:47:15 PM]

USERRA Information Request.

(M-F); e-mail [email protected] or complete the form
below.
If you are a Uniformed Service (National Guard, Reserve, the
National Disaster Medical System (NDMS)) member desiring to
have an Ombudsman assist you and your employer resolve a
conflict, call ESGR's toll-free number, 1-800-336-4590 (select
option 1), between 8 AM and 6 PM EST (M-F) or submit a
USERRA Support Request.

REQUESTOR INFORMATION
(Items marked with an asterisk(*) are required.)
DATE SUBMITTED:

10/31/2023 2:42:11 PM
* I AM:

Please
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One
Please
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One

Name

* First

MI

* Last

* EMAIL ADDRESS:

* TELEPHONE NUMBER:

ALTERNATE TELEPHONE
NUMBER:

* STATE

* ZIP CODE

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State
Select
State

https://www.esgr.mil/USERRA/USERRA-Contact/USERRA-Information-Request/t/0[10/31/2023 2:47:15 PM]

USERRA Information Request.

HOW DID YOU HEAR ABOUT ESGR?

Please
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One
Please
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One

* USERRA QUESTION

You have 250 characters

Please note: This form takes 20-30 seconds to submit. Please
only click the Submit button once. Once submitted, you will be
directed to a completion page and receive a confirmation email.

Submit
DD FORM 3021
OMB CONTROL NUMBER: 0704-ERRA
OMB EXPIRATION DATE: Submitted
AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information,
0704-ERRA, is estimated to average of less than five minutes per
response, including the time for reviewing instructions, searching
existing data sources, gathering, and maintaining the data
needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or
burden reduction suggestions to the Department of Defense,
Washington Headquarters Services, at [email protected]. Respondents should be
aware that notwithstanding any other provision of law, no person
shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid
OMB control number.

https://www.esgr.mil/USERRA/USERRA-Contact/USERRA-Information-Request/t/0[10/31/2023 2:47:15 PM]

USERRA Information Request.

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
https://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:
https://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx
.
Disclosure: Voluntary; however, failure to provide accurate
contact information and other solicited information may delay or
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USERRA Information Request.

prevent ESGR from processing the request.

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