§ App D

App. D

______________________________________ Case No. ______________________________________

Initiating Party

______________________________________ Date ______________________________________

Responding Party

Starting Time ______________________________________ Ending Time ______________________________________

If a mediation session was not held, indicate whose absence was responsible: (a.) Initiating party, (b.) responding party, or (c.) both parties. ____________

If a mediation session was held, please complete the remainder of this record.

1. Nature of Dispute (briefly describe) ______________________________________

______________________________________

2. Relationship of Parties (briefly describe) ________________________________

________________________________

3. Persons, other than the parties, present at mediation (name, address, telephone, relationship)

4. Indicate at what stage the mediation session terminated:

______ Introduction

______ Information exchange

______ Negotiations

______ Agreement

5. Comments __________________________________________________________________

__________________________________________________________________

6. If there is a referral to another agency, indicate which party was referred and to what agency

7. Describe follow-up plan ____________________________________________________

____________________________________________________

8. Recommendations and Remarks _______________________________________________

_______________________________________________

________________________________________________________________________________ Mediator