REQUEST FOR MEDIATION

SFEB DISPUTE RESOLUTION PROGRAM

Agency/Organization
Name of Mediation Point of Contact (POC)
POC Title
Work Address
Line 1
Line 2
City
State
Zip / -
Work Telephone(s) / -- Ext:
Work Fax / --
Work Email / @

Type of Mediation Requested:

Number of people attending the mediation:

Description of issue(s) requiring mediation:

Desired Resolution/Remedy:

Desired Mediation Date(s) and Start Time(s) (We ask participants to reserve the entire day to mediate):

Where would you like the mediation to take place?

If your agency/organization will be hosting the mediation, please provide the following information:

  1. Meeting location (Building address, room number, etc.)?
  1. Parking instructions for mediators?

Name(s) and Contact Information for Mediation Attendees

Mediation attendees will need a private location to conduct the pre-mediation intake call.

Have all mediation participants voluntarily agreed to participate?

Attendee 1
Position
Physical Work Location
Work Phone / -- Ext.
Cell Phone / --
Email / @
Dates/Times Available for Intake Call
Attendee 2
Position
Physical Work Location
Work Phone / -- Ext.
Cell Phone / --
Email / @
Dates/Times Available for Intake Call
Attendee 3
Position
Physical Work Location
Work Phone / -- Ext.
Cell Phone / --
Email / @
Dates/Times Available for Intake Call
Attendee 4
Position
Physical Work Location
Work Phone / -- Ext.
Cell Phone / --
Email / @
Dates/Times Available for Intake Call

Will a Union Representative attend the mediation? If yes, name?

**If more than four people will be attending the mediation, please attach a document with their information.

Settlement Process Information

Regarding your agency/organization settlement process, please answer the following:

  1. Does your agency/organization have a settlement template that must be used? If yes, please provide a copy.
  1. Is a handwritten settlement acceptable?
  1. The agency/organization must confirm that the individuals at the mediation session will have settlement authority or will be able to timely contact the person with settlement authority.
  1. If the person with settlement authority will not be at the mediation session, please provide the following information:

Name:

Title:

Phone #:

Fax #:

Email:

  1. Does the settlement agreement need to be reviewed by legal counsel prior to signing?
  1. If yes, please describe the process that is in place to conduct this review, and approximately how long the review typically takes.
  1. Have you considered your range of settlement options and what you are willing to offer?
  1. Have the people who will be representing the agency discussed possible settlement options with the approving authority (if the approving authority will not be attending the mediation); and do they clearly understand what will and will not be acceptable to the approving authority?
  1. Is there any additional information that you would like to share with the mediators?

Please return this Request for Mediation form to:

Brett Eckelberg

Seattle Federal Executive Board

Dispute Resolution Program Manager

FOR SFEB OFFICE USE ONLY

SFEB DR Case Number: -

Intake completed by:

Mediators:

Observer(s) (if any): and