UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF ILLINOIS, WESTERN DIVISION MEDIATOR CERTIFICATION OF SESSION (TO BE COMPLETED AT THE END OF EACH MEDIATION SESSION) Mediator Name:_____________________________ Case Number:_______________ The undersigned mediator, appointed pursuant to order entered on the ____ day of __________, 20__, reports to the Court as follows: A. A mediation session was scheduled for and held on _________________________. B. A settlement of this matter [ ] has been reached [ ] has been reached in part [ ] has not been reached C. [If a settlement has not been reached and the mediation is ongoing] The mediation has been continued for another session to be held on _________________. D. [If a settlement was reached] The party designated to prepare the settlement agreement and stipulation to dismiss is _________________________________; to be submitted to the court by_____________. [date] IF THIS IS THE FINAL MEDIATION SESSION IN THIS CASE, PLEASE CONTINUE: Date mediation began:____________ Date ended:_______________ Number of Sessions:_____ Hours in mediation:_____________ Hours of Preparation:_____________ How many from each category attended? _______ Lawyers _______ Clients _______ Non-parties ( please list, e.g., witnesses, spouse)______________________________ Which of the following were used to conduct or assist in the mediation process? [ ] In-person meetings _____% [ ] Telephone _____% [ ] E-mail or internet _____% Signature of Mediator:_______________________________ Dated:_____________________ Rev. 01/03 American LegalNet, Inc. www.FormsWorkFlow.com