VETS Form 1010 USERRA/VP/VEOA Claim Form

OMB NO. 1293-0002 (XX/XX/XXXX)
VETS USERRA/VP/VEOA Form 1010 (REV XX/XXXX)

U.S. Department of Labor
Veterans' Employment and Training Service
USERRA/VP/VEOA Claim Form
Instructions

This form may be used to submit claims to the U.S. Department of Labor (DOL), Veterans' Employment and Training Service (VETS) for potential violations
covered under the Uniformed Services Employment and Reemployment Rights Act (USERRA) or the laws and regulations relating to Veterans’ Preference (VP)
or the Veterans' Employment Opportunities Act (VEOA) in Federal employment.
Claimants who wish to submit a USERRA or VP claim directly to VETS may do so at https://vets1010.dol.gov/
Claimants who wish to file a claim using this form, must file the form by email, fax, or mail. Claims filed by email must be sent to VETS1010@dol.gov. Claims
filed by fax must be sent to (404) 562-2313. Instructions for mailing a printout of this form may be found on the VETS USERRA/VP/VEOA Form 1010(a).
Instructions for completing this form can be found on the VETS USERRA/VP Form 1010(a). For additional assistance, contact us at VETSCompliance@dol.gov

Section A. Claimant Information

1a. Last Name

1b. First Name

2a. Street Address

1c. Middle Initial

2b. City

2c. State

2d. Country

3. Email Address

2e. Zip/Postal Code
4. Cell Phone Number

6. Social Security Number

5. Home Phone Number

7. Have you served, or are you serving in a uniformed service covered by USERRA?

Yes

8. Do you have a military service-connected disability?

Yes

No

9. What type of claim are you filing?

-Select-

No

Section B. Employer Information

1. Are you currently employed?

2. Is the employer that is the subject of your claim your current employer?

Yes

No

Yes

3a. Name of the current, prospective, or former employer that is the subject of your claim.

No

3b. Type of Employer

-Select4. Title of the Position or Occupation Related to Your Claim (the job that you either now hold, used to hold, or applied for, with this employer)
5a. Pay Rate

5b. Per

5c. Does this position receive compensation for overtime or commissions?

-Select-

Yes

6a. Dates of Employment

From:

7a. Street Address

OR

To:

7c. State

No

6b. Date of Application/Interview
7b. City

7d. Country

7e. Zip/Postal Code

8a. Principle Employer Representative (PER) Name

8b. PER Title

9. PER Email Address

10a. PER Phone Number

8c. PER Type

-Select-

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10b. Extension

OMB NO. 1293-0002 (XX/XX/XXXX)
VETS USERRA/VP/VEOA Form 1010 (REV XX/XXXX)

Section C. USERRA Eligibility Information

If your claim is for an alleged Veterans Preference or VEOA violation, skip to section E.
1. Uniformed Service Branch Related to Claim
2. Have you been separated or discharged from uniformed service?

-Select-

Yes

No

3. Character of Service Upon Discharge or Separation 4a. Uniformed Service Dates

-Select-

From:

OR

4b. Examination or Rejection Date

To:

If your claim involves reemployment following uniformed service, answer the following questions:
5. Was notice of uniformed service provided to your employer?
6. How was the notice provided to your employer?

Yes

No

Written

7a. Who provided the notice to your employer?

Myself

9. Date Applied for Reemployment

Yes

10b. Date Reemployed/Reinstated

No

10d. Reemployed/Reinstated with Correct Pay?

No

Yes

No

Section D. USERRA Claim Information

1a. Was the Employer Support of the Guard and Reserve (ESGR) involved in handling you claim?

Yes

Both

Orally

8. When was notice provided to your employer?

Someone Else
10a. Were you Reemployed or Reinstated?

10c. Reemployed/Reinstated to Proper Position?

Yes

7b. Name, if Someone Else

OR

10e. Date of Denial

1b. Most Recent ESGR Contact Date

No
Select Yes or No for each statement below.

2a. I was denied reemployment/reinstatement into my proper position after returning from
uniformed service.

Yes

No

2b. I was denied proper reemployment/reinstatement after returning from uniformed service due
to a disability that was incurred or aggravated during that period of uniformed service.

Yes

No

2c. I was denied initial employment based on my uniformed service membership; or application,
obligation, or performance of uniformed service.

Yes

No

2d. I lost or was terminated from employment based on my membership, application, or
obligation to perform uniformed service.

Yes

No

2e. I was denied one or more benefits of employment (as described in Section D, 3a to 3i)
based on my membership, application, or obligation to perform uniformed service.

Yes

No

2f. I was retaliated against for taking an action or enforcing a protection afforded to someone
else covered under USERRA.

Yes

No

2g. I was retaliated against for testifying or making a statement in connection with a USERRA
investigation or proceeding.

Yes

No

2h. I was retaliated against for my participation in another USERRA investigation or proceeding,
other than making a statement or testifying.

Yes

No

Yes

No

2i. I was retaliated against for initiating a previous investigation or proceeding to protect my
USERRA rights.

If your claim involves the loss of a benefit of employment, select the checkbox for each benefit of employment.
3a. Status

3b. Pay Rate

3c. Seniority

3d. Pension

3e. Promotion

3f. Vacation / Leave

3g. Health Benefits…........................................….......Issue: -Select3h. Other Non-Seniority Benefits…....................Description:
3i. Other….........................................................Description:

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OMB NO. 1293-0002 (XX/XX/XXXX)
VETS USERRA/VP/VEOA Form 1010 (REV XX/XXXX)

Section E. Veterans Preference/VEOA Eligibility Information

If your claim is for an alleged USERRA violation, skip to section H.
2. Position Job Series
3. Pay Schedule
4. Pay Grade

1. Type of Claim

-Select5. Federal Agency Name

6. Sub-Agency or Department Name

7. Most Recent Branch of Uniformed Service

8. Have you been separated or discharged from uniformed service?

-Select-

Yes

No

9. Character of Service Upon Discharge or Separation

10. Uniformed Service Dates

-Select-

From:

To:

Section F. VP/VEOA Federal Hiring Claim Information
1. Vacancy Announcement Number

If your claim is in regard to a reduction in force, skip to section G.
2. Announcement Type
3. Preference/Eligibility Claimed During Application

-Select4a. Vacancy Open Date 4b. Vacancy Close Date

1. Position Title from SF-50

7. Date of Most Recent SF-50

6. Date of Decision, Notice, or Non-Selection

Section G. VP Reduction in Force (RIF) Claim Information

2. Veterans Preference from SF-50 3. Tenure from SF-50

4. Veterans Preference for RIF from SF-50

Yes

5. Application Date

No

-Select-

-Select-

5. Position Occupied from SF-50

6. FLSA Category from SF-50

8. Date Notified of RIF

9. Date of RIF or Proposed RIF

Section H. USERRA Remedies

1. List the Remedy(ies) you are seeking for any USERRA Reemployment/Reinstatement related issue(s).

2. List the Remedy(ies) you are seeking for any USERRA Discrimination or Retaliation related issue(s).

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OMB NO. 1293-0002 (XX/XX/XXXX)
VETS USERRA/VP/VEOA Form 1010 (REV XX/XXXX)

Section I. Claimant Demographic Information

1. Do you have a non-service-connected disability?

Yes

2. Date of Birth

3. Sex (Select the one that applies)

No

Female

4. What is your race and/or ethnicity? (Select all that apply and enter additional details in the spaces below)

Male

American Indian or Alaskan Native - Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of
Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.
Asian - Provide details below
Chinese

Asian Indian

Vietnamese
Korean
Enter, for example, Pakistani, Hmong, Afghan, etc.

Filipino
Japanese

Black or African American - Provide details below
African American

Haitian

Jamaican

Nigerian
Ethiopian
Somali
Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.
Hispanic or Latino - Provide details below
Mexican

Puerto Rican

Salvadoran

Cuban

Dominican

Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.
Middle Eastern or North African - Provide details below
Lebanese

Iranian

Egyptian

Syrian

Iraqi

Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.
Native Hawaiian or Pacific Islander - Provide details below
Native Hawaiian

Samoan

Chamorro

Tongan

Fijian

Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.
White - Provide details below
English

German

Irish

Italian

Polish

Scottish

Enter, for example, French, Swedish, Norwegian, etc.

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OMB NO. 1293-0002 (XX/XX/XXXX)
VETS USERRA/VP/VEOA Form 1010 (REV XX/XXXX)

Section J. Comments/Notes

1. Enter any other notes or comments regarding your claim that you feel are necessary to process and assign your claim to an investigator.

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OMB NO. 1293-0002 (XX/XX/XXXX)
VETS USERRA/VP/VEOA Form 1010 (REV XX/XXXX)

Section K. Punishment for Unlawful Statements
The information provided in this complaint will be utilized by the U.S. Department of Labor, Veterans’ Employment and Training Service
(VETS) to initiate an investigation of alleged violations of the Uniformed Services Employment and Reemployment Rights Act (USERRA), Title
38, USC, §§ 4301-4335; and/or the laws and regulations relating to veterans’ preference in Federal employment, including 5 USC § 3330a3330c, and eligibility for Federal employment described in the VEOA. Potential claimants should keep in mind that it is unlawful to “knowingly
and willfully” make any “materially false, fictitious, or fraudulent statements or representation” to a federal agency. Violations can be punished
under Section 2 of the False Statements Accountability Act of 1996 by a fine and/or imprisonment of not more than 5 years. 18 USC § 1001.

Section L. Paperwork Reduction Act Statement
The OMB control number for this collection is 1293-0002 and expires on April 30, 2026. According to the Paperwork Reduction Act of 1995, no
person is required to respond to a collection of information unless such collection displays a valid OMB control number.
Collection of this information is authorized by 38 USC § 4322(b) and 5 USC § 3330a(a)(2)(B). The obligation to respond to this collection is
required to initiate a USERRA or VP/VEOA investigation. We estimate it takes about 45 minutes to complete this collection of information,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.
Please send comments regarding the burden estimate or any other aspect of this collection of information to the Veterans' Employment and
Training Service, 200 Constitution Ave NW, Room S-1325, Washington, DC 20210 or VETSCompliance@dol.gov and reference OMB control
number 1293-0002.
Note: If this form can only be submitted by mail, please see instructions for submission by mail in the VETS USERRA/VP Form 1010(a).

Section M. Privacy Act Statement
The primary use of this information is by staff of the Veterans’ Employment and Training Service in investigating cases under USERRA or the
laws and regulations relating to veterans’ preference in Federal employment. Disclosure of this information may be made to: a Federal, state
or local agency for appropriate reasons; in connection with litigation; and to an individual or contractor performing a Federal function.
Furnishing the information on this form, including your Social Security Number, is voluntary. However, failure to provide this information may
jeopardize the Department of Labor’s ability to provide assistance or complete an investigation of your complaint.

Section N. Notification of Claimant's Rights
For claims arising under USERRA, a person has a right to commence an action for relief directly against the employer in the appropriate
federal district court (in the case of a complaint against a State or private employer), pursuant to 38 USC § 4323(a)(3), or the Merit Systems
Protection Board (in the case of a complaint against a Federal executive agency or the Office of Personnel Management), pursuant to 38 USC
§ 4324(b).
For claims arising under VP/VEOA, a person may file a complaint with the Secretary of Labor within 60 days after the date of the alleged
violation, pursuant to 5 USC § 3330a(a). The Secretary shall investigate the complaint under 5 USC § 3330a(b), and, if unable to resolve the
complaint within 60 days, the Secretary will notify the person of the results of the investigation, pursuant to 5 USC § 3330a(c). The person
may appeal to the Merit Systems Protection Board on or after the 61st day after the complaint was filed with the Secretary, but not later than
15 days after the person receives notification from the Secretary of the results of the investigation, pursuant to 5 USC § 3330a(d).

Section O. Certification and Signature
By my signature I certify that the above information is true and correct to the best of my knowledge and belief. I authorize the U.S. Department
of Labor to contact the employer identified in Section B or any other person with information concerning this claim. I further authorize my
employer or any other person to release such information to the U.S. Department of Labor. Pursuant to 5 USC, § 552a(b) of the Privacy Act, I
authorize the U.S. Department of Labor, the U.S. Department of Veterans Affairs, and the U.S. Department of Defense to release information
and records necessary for the investigation and prosecution of my claim.
1. Signature

2. Date

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