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This is a sample Mediation Evaluation Form from the U.S. Department of Energy

Mediation Survey

Now that you have completed mediation, please take a few minutes to fill this out. Your input is very important and will help us improve this program. Your answers will be completely confidential, and will only be used in the aggregate for statistical purposes.

  1. In this mediation, were you the:
    • Complainant / Plaintiff (person with the complaint)
    • Respondent / Defendant
    • Other
  2. Were you mediating an:
    • EEO complaint
    • Grievance
    • Workplace concern
    • Other
  3. Your title:
  4. Your sex: O male O female
    Your age group: ________________
    Your grade: _________________
  5. What were the issues/concerns discussed at mediation?
  6. What is your relationship to the other party at the mediation? (e.g., first level supervisor, second level, co-worker, team leader/member, etc.)
  7. If you brought someone to the mediation what was their relationship to you? (e.g., co-worker, family member, union representative, attorney)
  8. Was it helpful to you to have that person there?
    • very helpful
    • somewhat helpful
    • slightly helpful
    • not helpful
  9. Who else was at the mediation (e.g.. someone from H.R., second line management, etc.)?
  10. Was there someone else who would have been helpful to have at the mediation?
    • yes
    • no
  11. If so, who?
  12. Approximately how many hours did you spend in mediation?
  13. Approximately how much time elapsed from the beginning of mediation until the end?
  14. Who suggested mediation?
  15. The mediator(s) were from:
    • DOE
    • another Federal agency
    • Federal Mediation & Conciliation Service (FMCS)
    • a DC agency
    • private contractor
    • other

The following questions ask about your experiences in the Mediation.

  1. My experience participating in the mediation was completely satisfactory.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  2. I felt the mediation process was entirely fair.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  3. The mediator(s) did a good job of explaining the mediation process.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  4. Participating in the mediation took too much of my time.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  5. I was treated with respect during the mediation.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  6. During the mediation, I was given ample time to tell my side of the story.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  7. We were able to discuss all of the important issues during mediation.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  8. I trusted the mediator(s).
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  9. The mediator(s) maintained a neutral position towards both parties.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  10. Both parties, rather than the mediator(s), made the decisions about the outcome of the mediation.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  11. I had enough information to prepare for the mediation.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  12. If I had another dispute or problem like this one, I would want to try mediation to resolve it.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  13. I would recommend mediation to others at the Department.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  14. If not, why not?
  15. I think my relationship with the other party will be improved because we participated in mediation.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  16. I feel I had a better outcome through mediation than if I used other more traditional methods.
    • agree strongly
    • agree somewhat
    • disagree somewhat
    • disagree strongly
  17. Did you reach an agreement? (If yes please answer questions 32-36. If no please continue to question 37.)
    • yes
    • no
  18. If an agreement was reached, were you satisfied with the terms?
    • very satisfied
    • somewhat satisfied
    • slightly satisfied
    • not satisfied
  19. What were the general terms of your agreement?
  20. What would you have done if an agreement was not reached in mediation?
  21. How long do you think it would have taken you to get the problem resolved if you did not mediate?
  22. If no agreement was reached, do you believe the mediation was still helpful?
    • very helpful
    • somewhat helpful
    • slightly helpful
    • not helpful
  23. If you found there were benefits from the mediation regardless of whether you reached an agreement, please describe them:
  24. What did you like best about mediation?
  25. What, if anything, did you like least about mediation?
  26. How did you hear about the DOE Mediation Service?
  27. Any comments that might help us improve this program?
  28. Were you able to fill out this survey in a reasonable amount of time?
    • yes
    • no
  29. Your name: (OPTIONAL)

Thank you for your comments.