Court of Appeal, Fifth Appellate District CIVIL APPEAL CASE SCREENING QUESTIONNAIRE TO DETERMINE SUITABILITY FOR MEDIATION This questionnaire will assist the court in selecting cases for mediation to be conducted by a sitting justice of this court. The court intends to select cases shortly after the notice of appeal is filed and before the expense of preparing the record on appeal and appellate briefs has been incurred, This questionnaire is to be completed and signed by each party, or their counsel of record, and served on all other parties, or counsel of record, and filed with the court within ten (10) calendar days of mailing of this questionnaire. Case Name and Court of Appeal Number: _______________________________________________________________________________ Name of Attorney: _______________________________________________________________________________ Name(s) of Client(s): _______________________________________________________________________________ _______________________________________________________________________________ Appellant or Respondent: _________________________________________________________ Trial Court Venue: _______________________________________________________________ Name of Trial Judge: _____________________________________________________________ Facts of Dispute: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ PLEASE ATTACH A COPY OF THE VERDICT, ORDER, OR JUDGMENT APPEALED FROM What are the issues on appeal? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Identify all prior mediations/settlement conferences by date and state names of mediators/judges: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com Describe any other matters that will assist the Court in deciding whether this case is suitable for mediation: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Do you and your client believe that this case has a reasonably good chance of settling at an appellate court mediation: Yes No If "yes," why do you think so? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ If "no," why do you think so? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ On a scale of 1 to 10, with "1" signifying no chance of resolving and "10" signifying a certainty of resolving, how do you rate the chances that mediation will be successful? ________________________ Date Notice of Appeal filed: ________________________ Date: ___________________________ _________________________________________ Signature _________________________________________ Print Name of Party or Attorney 2 American LegalNet, Inc. www.FormsWorkFlow.com