Applicant/Recipient Mediation Questionnaire

In the interest of continuously improving the mediation process, you are invited to share opinions about your mediation experience. Information that you include in this questionnaire will be used to make adjustments that will lead to improving the mediation process used in state government. Your investment of time and attention in this evaluation is much appreciated.

Date:
Recipient:
Respondent:
Mediator:

In the following, circle the one response that best describes your response to each question.

SA = Strongly Agree / A = Agree / N = Neutral / D = Disagree / SD = Strongly Disagree
1. The facility used for mediation provided a satisfactory environment. / SA / A / N / D / SD
2. The mediation location was reasonably convenient for me. / SA / A / N / D / SD
3. The grievance request was given prompt attention. / SA / A / N / D / SD
4. The mediation was held in a timely fashion. / SA / A / N / D / SD
5. The mediator(s) explained the mediation process to my satisfaction. / SA / A / N / D / SD
6. I had sufficient time to tell my side of the story. / SA / A / N / D / SD
7. The mediator was fair and impartial. / SA / A / N / D / SD
8. The co-mediator was fair and impartial. / SA / A / N / D / SD
9. The mediator treated me with respect. / SA / A / N / D / SD
10. The co-mediator treated me with respect. / SA / A / N / D / SD
11. The agency respondent treated me with respect. / SA / A / N / D / SD
12. Mediation resolved this grievance to my satisfaction. / SA / A / N / D / SD
13. Mediation provided a positive opportunity to discuss this grievance. / SA / A / N / D / SD
14. I felt positive about the overall mediation process. / SA / A / N / D / SD

Comments: ______

______

______

Med-06 (10/08)