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Mediation Feedback Form
TO BE COMPLETED BY THE MEDIATION PARTICIPANTS
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Name of mediator:
*
Your answer
Date of mediation:
*
MM
/
DD
/
YYYY
The conflict or dispute was about:
Choose
Personality
Tasks
Resource allocation
Performance
Work life balance
Interpersonal relationships
Trust
Communication
Culture
Roles
Values
Ability
Competence
Environment
Treatment
Other (please describe in the comments section below)
Have you participated in mediation before?
Yes
No
Clear selection
Was the time and place scheduled for the mediation session convenient for you?
Yes
No
Clear selection
Did you reach an agreement to settle your dispute?
Yes
No
Clear selection
If you reached an agreement to settle, do you consider it to be fair?
Yes
No
Clear selection
Would you use mediation again?
Yes
No
Clear selection
If you did not reach an agreement to settle, do you feel better or differently about the dispute?
Yes
No
Clear selection
Please indicate the number which best reflects how you feel about the following statements:
Strongly agree (1); Agree (2); Not sure (3); Disagree (4); Strongly disagree (5)
1.
The amount of time spent in mediation was appropriate.
1
2
3
4
5
Clear selection
2.
The information and resources I received about the mediation process was helpful.
1
2
3
4
5
Clear selection
3.
The mediator allowed me to fully present information and my side of the dispute.
1
2
3
4
5
Clear selection
4.
I fully understood what was going on at all times during the mediation.
1
2
3
4
5
Clear selection
5.
Overall, I was satisfied with the mediation process.
1
2
3
4
5
Clear selection
6.
The mediator explained the mediation process clearly.
1
2
3
4
5
Clear selection
7.
The mediator effectively clarified my key issues and concerns.
1
2
3
4
5
Clear selection
8.
There was no pressure from the mediator to settle the dispute.
1
2
3
4
5
Clear selection
9.
The mediator treated all the persons fairly.
1
2
3
4
5
Clear selection
10.
The mediator helped to create realistic options for settling the dispute.
1
2
3
4
5
Clear selection
11.
The mediator understood the issues involved.
1
2
3
4
5
Clear selection
12.
Overall, I was satisfied with the mediator.
1
2
3
4
5
Clear selection
Please leave any additional comments here:
Your answer
Would you like to offer a testimonial? (Including your name is optional.)
Your answer
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