Confidential Questionnaire
Business Mediation Assessment Interview #1
CONTACT INFORMATION
Company Name:Corporate Name:
Company Address:
Primary Contact:
Office Phone:
Cell Phone:
Home Phone:
Private Email:
Preferred Contact Method: q office phoneq cell phoneqhome phoneqemail
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PART I About your firm
THE COMPANY
Nature of Business (i.e. healthcare, health company, education, service, retail, manufacturing, professional etc.)
______
Type of Enterprise: (corporation, small business, family business) ______
Locations: ______
Key Customer / Stakeholder Groups: ______
OPERATIONAL INFORMATION (please check appropriate boxes)
Client’s Position:
qPresident/CEO qCFO q Director Other ______
Involvement/Responsibilities:
qDaily Operations qAdministrative Only qAbsentee Other ______
Number of employees_____ full-time _____ part-time _____ Independent Contractors______
Are your employees members of a trade union? qYes qNo
If yes, please briefly describe your relationship with the union.
Is there a full time sales staff? qYes qNo
Is there a full time IT staff? qYes qNo
Is there a full time marketing staff? qYes qNo
Is there a website for the company? qYes qNo Address: ______
Do you have board of directors? qYes qNo
If yes, please briefly describe your relationship with the board.
OWNERSHIP STRUCTURE (please check appropriate boxes)
Business Ownership: qSole ProprietorqC-Corp. qS-Corp. qPartnershipqLLC
Has a valuation ever been done on the business? q Yes q No
Is a law suit pending on the business? q Yes q No
Is the company?q A Franchise q Independent
Owner Name / %Can you provide us with an organizational chart? q Yes q No
What are the strengths of your company? ______
What are the most significant challenges facing your company? ______
Briefly, please describe what prompted you to contact us:
______
PART II About your practices
Rank your view of your company’s performance from 1 to 5 (low to high) for the factors listed below. For each factor, list the words (adjectives) that you would use to describe each of the components of the company.
1. Conflict Practices
Ranking: Below Above
Poor Average Average Average Excellent
1.1 Current 1 2 3 4 5
1.2 Desired 1 2 3 4 5
1.3 What words (adjectives) would you use to describe the company’s current conflict practices?
1.4 What words (adjectives) would you use to describe your desired conflict practices in the future?
1.5 Where does conflict surface in your company?
1.5 Additional Comments:
2. Individual Communication Practices
Ranking: Below Above
Poor Average Average Average Excellent
2.1 Current 1 2 3 4 5
2.2 Desired 1 2 3 4 5
2.3 What words (adjectives) would you use to describe your current communication
practices?
2.4 What words (adjectives) would you use to describe your desired communication practices in the future?
2.5 Additional Comments:
3. Communication Practices within the Organization
Ranking: Below Above
Poor Average Average Average Excellent
3.1 Current 1 2 3 4 5
3.2 Desired 1 2 3 4 5
3.3 What words (adjectives) would you use to describe the company’s current communication
practices?
3.4 What words (adjectives) would you use to describe your desired communication practices in the future?
3.5 Additional Comments:
4. Business Change (clear mission, vision for future, path to future)
Ranking: Below Above
Poor Average Average Average Excellent
4.1 Current 1 2 3 4 5
4.2 Desired 1 2 3 4 5
4.3 What words (adjectives) would you use to describe the company’s current business change?
4.4 What words (adjectives) would you use to describe your desired business change in the future?
4.5 Additional Comments:
5. Customer/Client Service (if applicable)
Ranking: Below Above
Poor Average Average Average Excellent
5.1 Current 1 2 3 4 5
5.2 Desired 1 2 3 4 5
5.3 What words (adjectives) would you use to describe the company’s current customer/client
service?
5.4 What words (adjectives) would you use to describe your desired customer/client service in the future?
5.5 What means do you use to track your client service ability?
5.6 Additional Comments:
6. Business Work Culture (teamwork, morale, commitment, innovation)
Ranking: Below Above
Poor Average Average Average Excellent
6.1 Current 1 2 3 4 5
6.2 Desired 1 2 3 4 5
6.3 What words (adjectives) would you use to describe the company’s current business work
culture?
6.4 What words (adjectives) would you use to describe your desired business work culture in the future?
6.5 Additional Comments:
7. Internal Relations (internal employees, board members)
Ranking: Below Above
Poor Average Average Average Excellent
7.1 Current 1 2 3 4 5
7.2 Desired 1 2 3 4 5
7.3 What words (adjectives) would you use to describe the company’s current internal stakeholder
relations?
7.4 What words (adjectives) would you use to describe your desired internal stakeholder relations in the future?
7.5 Additional Comments:
8. External Relations (customers, clients, community, natural environment)
Ranking: Below Above
Poor Average Average Average Excellent
8.1 Current 1 2 3 4 5
8.2 Desired 1 2 3 4 5
8.3 What words (adjectives) would you use to describe the company’s current external stakeholder
relations?
8.4 What words (adjectives) would you use to describe your desired external stakeholder relations in the future?
8.5 Additional Comments:
9. Personal Leadership Practices
Ranking: Below Above
Poor Average Average Average Excellent
9.1 Current 1 2 3 4 5
9.2 Desired 1 2 3 4 5
9.3 What words (adjectives) would you use to describe your current leadership practices?
9.4 What words (adjectives) would you use to describe your desired leadership practices in the future?
9.5 Additional Comments:
10. Organizational Management Practices
Ranking: Below Above
Poor Average Average Average Excellent
10.1 Current 1 2 3 4 5
10.2 Desired 1 2 3 4 5
10.3 What words (adjectives) would you use to describe the company’s current management
practices?
10.4 What words (adjectives) would you use to describe your desired management practices in the future?
10.5 Additional Comments:
11. Company’s Overall Capacity to Get the Job Done
Ranking: Below Above
Poor Average Average Average Excellent
11.1 Current 1 2 3 4 5
11.2 Desired 1 2 3 4 5
11.3 What words (adjectives) would you use to describe the company’s overall capacity to get the Job done?
11.4 What words (adjectives) would you use to describe your desired overall capacity to get the Job done in the future?
11.5 Additional Comments:
12. What words would you use to describe your employees?
13. What words would you use to describe this company’s financial health?
14. What words would you use to describe rate of change this company is experiencing?
And, in what direction is this change going?
15. If your company was a car, what kind car would it be?
This company is like a ______because______.
16. What are this company’s Achilles’ Heels (challenges)?
17. What is the question this company needs to discuss, that we have not or will not discuss?
18. What else would it be helpful for us to know about your company?
PART III Changes
Any significant changes taking place in your company?
£ Merger of Existing Businesses
£ Acquisition of an Existing Business
£ Sale of an Existing Business
£ Purchase of an Existing Business
£ Expansion of an Existing Business
£ Other ______