EEOC Seal

U.S. Equal Employment Opportunity Commission



This is a sample Intake Sheet from the U.S. Department of the Air Force

Air Force Mediator Case Management Worksheet

I. Information About the Parties

Name of Complainant/Grievant:

Position and grade or rank:
Address:
Phone no: Home phone (optional):
Fax no: Duty Hours:
Email:

Name of Management Official:

Position and grade or rank:
Address:
Phone no.: Home Phone (optional):
Fax no.: Duty Hours:
Email:

Dates Complainant/Grievant Available:

Dates Management Official(s) Available:

What is the agreed upon time and place for the mediation conference?

II. Brief Description of the Issue(s)in Controversy

Complainant/Grievant's Information

  1. What is at issue in the dispute(s)?


  2. What management official(s) is/are involved in the controversies? How are they involved?


Respondent's Information

  1. What is at issue in the dispute(s)?


  2. Who has settlement authority in this matter?


  3. Who will need to be consulted if an acceptable settlement agreement is crafted? (It is recommended that you obtain the name, office and phone number of these individuals to ensure they are available by phone during the mediation session to ensure any proposed terms in the settlement agreement will be supported by these officials)

III. Scheduling the Mediation: Accounting for Special Needs of the Parties and Their Representatives, If Any

  1. Does either party have a disability that may require special considerations such as an access ramp for the disabled?
  2. Does either party currently plan to bring a representative (legal or non-legal) to this session? If so, who are they? What is their expected role?
  3. Name of Representative for Complainant/Grievant:
  4. Representative's address:

  5. Air Force Attorney or other management official attending:
  6. Phone number: Home Phone (optional):
    Fax number: Duty Hours:
    Email:
  7. Office address:
    Phone number: Home Phone (optional):
    Fax number: Duty Hours:
    Email:
  8. Who is the Air Force point of contact for reservation of the mediation conference room?
    Phone number: Home Phone (optional):
    Fax number: Duty Hours:
    Email:

IV. Recommended Points to Cover When Explaining What Mediation Is and Your Role in the Process

Complainant/Grievant does not waive his/her right to continue with the formal dispute resolution process by attempting mediation. If mediation does not succeed, the Complainant/Grievant may resume the formal process as long as applicable time limits are met.

NOTE: IF THE COMPLAINANT/GRIEVANT ASKS WHAT THE APPLICABLE TIME LIMITS ARE, PLEASE REFER THEM TO THE APPROPRIATE OFFICE TO OBTAIN THIS INFORMATION.

Mediation is a voluntary process. Mediation and any resulting settlement agreement depends on the voluntary agreement of the parties.

Explain why confidentiality and impartiality are keys to the success of mediation.

Explain what a caucus is and why it makes mediation a powerful dispute resolution process.

Mediation is not a legal proceeding so normal court rules do not apply.

Mediators are not judges; they do not determine who is right as a matter of law, nor do they provide legal counsel or advice to either party.

Parties have a right to bring legal counsel or any other type of representative to the mediation session if they so choose.

During the mediation session, either party is free to consult lawyers or other experts to ensure terms and conditions of a settlement are legal and that the parties have the authority to agree to them.

NOTE: AIR FORCE MEDIATOR/CASE INTAKE OFFICIAL SHOULD ARRANGE FOR SUCH EXPERTS TO BE AVAILABLE BY PHONE DURING THE MEDIATION SESSION.

The goal is a clearly written agreement acceptable to both parties.

The written agreement, when reviewed for legal sufficiency and determined to be properly authorized, is intended to be binding. [Remind the parties that the written settlement agreement may require a management and legal review before it becomes binding on the Government.

Settlement Agreements that result from mediations are enforceable to the same extent and using the same processes as any other administrative settlement for the type of dispute that gave rise to the complaint/grievance.]

Sessions last about four hours, so ensure they schedule at least six hours for the mediation session.

V. Best Practices Checklist

Action Dates

The following should be completed by the Mediator or the Case Intake Official

  1. If employee's position is included in the bargaining unit, verify that ADR has been negotiated and any bargaining obligations have been met.
  2. Contacted Complainant/Grievant by phone and explained the mediation process.
  3. Contacted Management Official by phone and explained the mediation process.
  4. Reached a conclusion that the dispute is amenable to mediation.
  5. Ensured that if one plans to bring a representative to the mediation that the other is notified of this.
  6. Reserved a mediation conference room on a date and for a time that Complainant/Grievant and Management Official have at least six hours set aside.
  7. Mailed or faxed mediation process letter to Complainant/Grievant so that it is received at least 48 hours prior to the mediation.
  8. Mailed or faxed mediation process letter to Management Official so that it is received at least 48 hours prior to the mediation.
  9. Obtained written confirmation that Complainant/Grievant understands and agrees to the mediation process specified in the mediation process letter received at least 48 hours prior to the mediation.
  10. Obtained written confirmation that the Management Official understands and agrees to the mediation process specified in the mediation process letter received at least 48 hours prior to the mediation.
  11. Confirmed availability of the mediation conference room prior to the mediation session.
  12. Confirmed Air Force subject matter experts are available by phone during the time scheduled for mediation to provide legal, policy, or practical advice regarding potential settlement options or terms.
  13. Made arrangements with relevant management officials and Air Force attorneys for an expedited review of the settlement agreement after mediation.
  14. Ensured appropriate accommodation if a disability or special need is identified by any of the parties.

The following are to be completed by the Mediator only

  1. Conducted the mediation.
  2. Completed settlement agreement coordination process.
  3. Prepared the mediation result and lessons-learned report.
  4. Submitted mediation results and lessons-learned to the Base ADR Program office.