Co-Mediator Name:

Date: / /

Please select the appropriate response and make any necessary comments.

I. ADHERENCE TO THE MEDIATION MODEL: Great Okay Improvement Needed

• Introductory Statement
• Initial Statements & Information Gathering
• Clarification & Problem I.D.
• Bargaining & Negotiation
• Agreement Writing
• Closure

Comment:

II. MAINTAINS CONTROL: Great Okay Improvement Needed

• Enforces groundrules
• Balances power of participants

Comment:

III. REMAINS IMPARTIAL/NON-JUDGMENTAL: Great Okay Improvement Needed

• Restates in neutral terms

Comment:

IV. DOES NOT LECTURE / MORALIZE: Great Okay Improvement Needed

• Suggests options, but does not dictate possible solutions

Comment:

V. DOES NOT DOMINATE DISCUSSION: Great Okay Improvement Needed

• Encourages parties’ to talk to each other

Comment:

VI. EFFECTIVE TECHNIQUE(S) OBSERVED: