U.S. DISTRICT COURT NORTHERN DISTRICT OF ILLINOIS (WESTERN DIVISION) MEDIATION EVALUATION FORM -- For Parties -Please promptly fill out this form after the mediation conference and return it to the ADR Administrator via fax at 815-987-4291. No case identification will be associated with these responses for purposes other than program evaluation. Name of Mediator: _____________________________________________________________ Case Number: _________________________________________________________ Date of Mediation: ___________________ Type of Case: _____________________________ Outcome: [ ] settled [ ] partially settled [ ] not settled [ ] continued for further mediation Number of mediation sessions held: __________ Are you the [ ] defendant Number of hours spent in mediation: ________ [ ] plaintiff Number of cases in which you have participated in mediation prior to this one: _________ 1. On a scale of 1 – 5 (1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree), please respond to the following: SD D N A SA a) The mediator was well-prepared for the mediation 1 2 3 4 5 b) I understood the mediation process: 1 2 3 4 5 c) The mediator allowed me to fully present my case: 1 2 3 4 5 d) The mediator carefully listened to my side of the case: 1 2 3 4 5 e) The mediator helped me to generate options for settling the dispute: 1 2 3 4 5 f) The mediation asked appropriate questions to determine the facts of the case: 1 2 3 4 5 g) Overall, I am satisfied with the mediation process: 1 2 3 4 5 h) The process was fair to all parties: 1 2 3 4 5 i) Overall, I am satisfied with what was accomplished in the mediation: 1 2 3 4 5 j) Overall, I am satisfied with the agreement (if reached): 1 2 3 4 5 2. Overall, how helpful or detrimental was the mediation in the resolution of this case? 1. [ ] Very detrimental; 2. [ ] Somewhat detrimental; 3. [ ] It had little impact on the case; 4. [ ] Somewhat helpful; 5. [ ] Very helpful 3. The overall length of mediation was: [ ] too long [ ] too short [ ] about right American LegalNet, Inc. www.FormsWorkFlow.com 4. Did the mediator appear to have a bias for the [ ] Plaintiff? [ ] Defendant? [ ] No Bias 5. Do you think the assignment of this case to mediation: [ ] Facilitated (or will facilitate) its early resolution [ ] Will increase time to resolution [ ] Will have no impact on time to resolution 6. Do you think the assignment of this case to mediation: [ ] Has reduced (or will reduce) litigation costs [ ] Will increase litigation costs [ ] Will have no effect on costs 7. If the case did not settle, why not? __________________________________________________________________________________ __________________________________________________________________________________ 8. Would you be willing to use mediation again? [ ] Yes [ ] No Why or why not? _________________________________________________________________ ________________________________________________________________________________ 9. Would you be willing to use this mediator again? [ ] Yes [ ] No Why or why not? _________________________________________________________________ ________________________________________________________________________________ 10. Comments on the mediator or the mediation process: American LegalNet, Inc. www.FormsWorkFlow.com