ETA Form 1010 "Eligibility Data Form"

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What Is ETA Form 1010?

This is a legal form that was released by the U.S. Department of Labor - Employment & Training Administration on December 1, 2013 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

Released on December 1, 2013;
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OMB NO. 1293-0002 (EXP 01/31/2020)

VETS/USERRA/VP Form 1010 (REV 12/2013)

ELIGIBILITY DATA FORM: For claims under the Uniformed Services Employment and Reemployment Rights Act (USERRA)

and/or claims under the Veterans’ Preference (VP) provisions of the Veterans Employment Opportunities Act of 1998

U.S. Department of Labor, Veterans’ Employment and Training Service

Mail (or FAX) to:

Veterans' Employment and Training Service

Phone: (866) 4-USA-DOL ((866)-487-2365))

U.S. Department of Labor

FAX:

(404) 562-2313

ATTENTION: Form 1010

61 Forsyth Street, S.W., Room 6T85

Atlanta, Georgia 30303

PLEASE TYPE OR PRINT

Section I: Claimant Information

Name:

Last Name

First Name

M.I.

2. Address:

Street

City

State

ZIP

. Social Security No:

. Home Phone:

. Cell Phone:

6. Email Address:

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

Yes

Section II: Uniformed Service Information

8. Serve(d) In:

Air National Guard

Army National Guard

Army Reserve

Air Force Reserve

Naval Reserve

Marine Corps Reserve

Coast Guard Reserve

Army

Air Force

Navy

Marine Corps

Coast Guard

Public Health Service

Other (Explain in “Comments”)

None (Retaliation Claim – Explain in “Comments”)

9. If Reserve/National Guard:

(a)

Name of Unit:

(b)

Unit Address:

(c)

Unit Phone:

10. Dates of Service (If applicable):

(a) From:

To:

(b) Date of Examination/Rejection for Service:

11. Type of Discharge or Separation:

Honorable Conditions

Entry Level

Uncharacterized

Medical

Other than Honorable

Other (Explain in “Comments”)

Not Applicable

Section III: Employer Information

12. Employer or Prospective Employer’s Name:

13. Address:

Street

City

State

ZIP

14. Principal Employer Contact (PEC):

(a) PEC Name/Title:

(b) PEC Phone:

15. Employment Dates (If applicable):

From:

To:

16. Since beginning work with this employer, has your cumulative uniformed service exceeded 5 years?

Yes

If YES, explain in Comments box at end of this claim form.

17. Name of Union(s) That Represent You:

18. Title of the Position or Occupation that is related to your claim (the job that you either now hold, or used to hold, or applied for, with this employer):

OMB NO. 1293-0002 (EXP 01/31/2020)

VETS/USERRA/VP Form 1010 (REV 12/2013)

ELIGIBILITY DATA FORM: For claims under the Uniformed Services Employment and Reemployment Rights Act (USERRA)

and/or claims under the Veterans’ Preference (VP) provisions of the Veterans Employment Opportunities Act of 1998

U.S. Department of Labor, Veterans’ Employment and Training Service

Mail (or FAX) to:

Veterans' Employment and Training Service

Phone: (866) 4-USA-DOL ((866)-487-2365))

U.S. Department of Labor

FAX:

(404) 562-2313

ATTENTION: Form 1010

61 Forsyth Street, S.W., Room 6T85

Atlanta, Georgia 30303

PLEASE TYPE OR PRINT

Section I: Claimant Information

Name:

Last Name

First Name

M.I.

2. Address:

Street

City

State

ZIP

. Social Security No:

. Home Phone:

. Cell Phone:

6. Email Address:

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

Yes

Section II: Uniformed Service Information

8. Serve(d) In:

Air National Guard

Army National Guard

Army Reserve

Air Force Reserve

Naval Reserve

Marine Corps Reserve

Coast Guard Reserve

Army

Air Force

Navy

Marine Corps

Coast Guard

Public Health Service

Other (Explain in “Comments”)

None (Retaliation Claim – Explain in “Comments”)

9. If Reserve/National Guard:

(a)

Name of Unit:

(b)

Unit Address:

(c)

Unit Phone:

10. Dates of Service (If applicable):

(a) From:

To:

(b) Date of Examination/Rejection for Service:

11. Type of Discharge or Separation:

Honorable Conditions

Entry Level

Uncharacterized

Medical

Other than Honorable

Other (Explain in “Comments”)

Not Applicable

Section III: Employer Information

12. Employer or Prospective Employer’s Name:

13. Address:

Street

City

State

ZIP

14. Principal Employer Contact (PEC):

(a) PEC Name/Title:

(b) PEC Phone:

15. Employment Dates (If applicable):

From:

To:

16. Since beginning work with this employer, has your cumulative uniformed service exceeded 5 years?

Yes

If YES, explain in Comments box at end of this claim form.

17. Name of Union(s) That Represent You:

18. Title of the Position or Occupation that is related to your claim (the job that you either now hold, or used to hold, or applied for, with this employer):

Section IV: Claim Information

19. Was the Employer Support of the Guard and Reserve (ESGR) involved in handling your claim initially?

Yes

Use items #20 and #21 to identify the program(s). (NOTE: Most claims – but not all – apply to only one program.)

For this claim to apply only to Veterans’ Preference (VP) in Federal Employment: Complete item #20, and skip #21.

•

For this claim to apply only to USERRA: …………………………………………….. Skip item #20, and complete #21.

For this claim to apply to both VP and USERRA: …………………………………… Complete both items #20 and #21.

•

20. Veterans’ Preference Issue (Check One):

Hiring

Reduction-in-Force (RIF)

21. USERRA Issue(s):

Military Obligations Discrimination

Reinstatement

Initial Hiring Discrimination

Discrimination as Retaliation for any Action

Status

Pay Rate

Seniority

Other Non-Seniority Benefits

Pension

Layoff

Promotion

Vacation

Health Benefits

Special Protected Period Discharge

Reasonable Accommodations/Retraining for Disabled

Reasonable Accommodations/Retraining for Non-Qualified/Non-Disabled

Other

If Claim Concerns Hiring, Promotion, RIF or Termination

22. Title of Position Held or Applied For:

23. Pay Rate:

24. Date of Application Employment/Promotion:

(a) Vacancy Announcement Number:

(b) Date Vacancy Opened:

If Claim Concerns Reemployment Following Service

25. Was Prior Notice of Service Provided to Employer?

Yes

No (If “No,” Explain in Comments)

26. (a) Who Provided Notice of Service to Employer?

Self

Other (name):

(b) Was the Notice of Service:

Written

Oral

Both

27. Name/Title of Person to Whom Notice of Service was Provided:

28. Date Applied for Reemployment:

OR Date Returned to Work:

29. Reemployment Application Made To:

Name:

Title:

30. Reemployed or Reinstated?

Yes (date):

(a) If YES, what position?

at what pay rate?

(b) If NO, Date denied:

Reason(s) given:

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, U.S.C., Sections 4301-4335; and/or the Veterans’ Preference (VP), provisions of

the Veterans Employment Opportunities Act of 1998 (VEOA), 5 U.S.C. §3330a-3330c. 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 U.S.C. § 1001.

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 my employer or any other person for

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 U.S.C., Section

552a(b) of the Privacy Act, I authorize the U.S. Department of Labor and the U.S. Department of Defense to release information and records necessary for the investigation and

prosecution of my claim.

SIGNATURE:

DATE:

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is

estimated to average 30 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this

burden, to the U.S. Department of Labor, Veterans’ Employment and Training Service, Room-S1316, 200 Constitution Avenue, N.W., Washington, DC 20210.

NOTIFICATION OF USERRA 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 U.S.C. § 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 U.S.C. § 4324(b).

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 laws/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 on your claim.

Continue in Comments box &/or use additional sheet(s) to explain items if needed – Sign and date form (above)

OMB NO. 1293-0002 (EXP 01/31/2020

VETS/USERRA/VP Form 1010 (REV 12/2013) – Page 2

Explain your claim in detail – List all remedies you seek

Use additional sheet(s) if needed – Initial & date each page at bottom

Comments:

INITIALS:

DATE:

Mail (or FAX) to:

Veterans' Employment and Training Service

Phone:

( 866) 4-USA-DOL ((866)-487-2365))

U.S. Department of Labor

FAX:

(404) 562-2313

ATTENTION: Form 1010

61 Forsyth Street, S.W., Room 6T85

Atlanta, Georgia 30303

OMB NO. 1293-0002 (EXP 01/31/2020)

VETS/USERRA/VP Form 1010 (REV 12/2013) – Page 3

Instructions for filing claims under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) and/or the Veterans’ Preference

(VP) provisions of the Veterans Employment Opportunities Act of 1998

Section I

•

Questions 1-7 - Self-explanatory. (Note: Social Security number is optional, but desired; or, you may instead just give “000-00-“ and then the last

four digits of your Social Security number.)

Section II

For this section please use the branch of service that you were, are or will be in when the allegations that lead you to file this claim occurred. For each question, answer

to the best of your ability only the questions that apply to you. This information must eventually be supported with documentation in order for the Veterans’

Employment and Training Service (VETS) to establish your eligibility under the law.

•

Question 8 – Mark the appropriate box to indicate the branch of service you that you are, have been, or will be a member of. (May skip if filing a VP

claim).

•

Question 9 - Fill in the specific information you have of your unit including name, address and phone number.

•

Question 10 -

a. Fill in the dates that you served in, the date that you began your service, the date that you will begin your service. OR

b. Fill in the date of examination/rejection for service.

•

Question 11 - Mark the appropriate box that best describes how you were discharged or separated. (If you have not yet been discharged, mark ”Not

Applicable.”)

Section III

Please report the information of the employer(s) that your claim involves as accurately as possible. This information will be used to establish a point of contact within

the company or agency.

•

Question 12 - Fill in the name of your employer or the employer that you applied for a position with.

•

Question 13 - Fill in the employer’s or potential employer’s mailing address.

•

Question 14 -

a. Fill in the name and, if possible the title of the person you are or have been in contact with regarding the position employed or applied for. (Often

a human resource specialist or supervisor.)

b. Fill in their phone number.

•

Question 15 - Fill in the dates that you have been employed with this employer; or, if still employed there, fill in just the “From” date that you started

working for this employer; or, if you have not yet started working there, fill in just the “From” date that you will start working for this employer.

•

Question 16 – (USERRA only) Mark the “no” box if you have not exceeded five cumulative years of uniformed service since beginning work with

this employer. Mark the “yes” box if you have exceeded five cumulative years of uniformed service since beginning work with this employer and

explain in the “Comments” section below.

•

Question 17 - Fill in the name of any Union(s) that may represent you. (May leave this question blank if filing a VP claim)

•

Question 18 - Fill in the title of the position you have now, or that you previously had, or that you applied for, with this employer.

Section IV

•

Question 19 – (USERRA only) Indicate if the Employer Support of the Guard and Reserve (ESGR) was involved in handling your complaint before

filing this Form 1010 claim with VETS.

Use Question #20 and/or #21 in this section to identify the program(s) for which you are filing this claim. (NOTE: Most claims – but not all – apply to

only one program.) To complete Question #20 and/or #21, please fill in the issue that best describes your claim.

•

For this claim to apply only to Veterans’ Preference (VP) in Federal Employment: Complete Question #20, and skip #21.

•

For this claim to apply only to USERRA: Skip #20 and complete #21.

•

For this claim to apply to both VP and USERRA: Complete both #20 and #21.

If Claim Concerns Hiring, RIF, Promotion or Termination

•

Question 22 - Fill in the title of the position that relates to this claim.

•

Question 23 – (USERRA only) Fill in the rate of pay for the position that relates to this claim.

•

Question 24 – (USERRA only) Fill in the date you applied for the position or promotion that relates to this claim.

a. Fill in the Vacancy Announcement Number.

b. Fill in the date the vacancy opened.

c. Fill in the date the vacancy closed.

If Claim Concerns Reemployment Following Service

•

Question 25 – (USERRA only) Fill in yes if you provided notice of your service to your employer before you began your military service. If not,

mark “no” and explain in the “Comments” section and continue to question 28.

•

Question 26 – (USERRA only)

a. Mark the “self” box if you provided the notice or the name of the person that provided the notice to your employer on your behalf.

b. Indicate how the notice was given and mark the appropriate box or boxes.

c. Fill in the date that the notice of service was provided to the employer.

•

Question 27 – (USERRA only) Fill in the name and title of the person to whom you provided the notice of service.

•

Question 28 – (USERRA only) Fill in the date you applied for reemployment or the date you returned to work.

•

Question 29 - Fill in the name and title of the person to whom you applied for reemployment.

•

Question 30 - If you have been reemployed or reinstated, mark the “yes” box and enter the date that you were reemployed or have been reinstated with

your employer and complete 30 (a). If you have not been reemployed or reinstated, mark the “no” box, skip 30 (a) and complete 30 (b) and (c).

a. Fill in your position and pay rate.

b. Fill in the date that your reemployment was denied and state the reason that was given. (If additional space is needed, you may explain in

“Comments” section).

c. Fill in the name and title of the individual within your employer who denied your reemployment.

Comments

Please explain in detail and be sure to include any relevant facts as to why you are filing this claim. Please be sure to also explain in detail what remedies (for example:

employment, reemployment rights, lost wages, seniority benefits, etc.) you seek by filing this claim.