COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. EVALUATION OF MEDIATION--PARTIES AND INSURERS : Plaintiff(s) Name of Case: -against- JUDICIAL SUBPOENA : Number of Hours in Session(s): : Mediator(s): : Date, Place of Mediation Session(s): Defendant(s) : .. ............. .... ...... I am:. . _____plaintiff. . . . . . . . . . . . . . . . . . . . . . . . . . This. mediation resulted in: _____defendant ____ full settlement of case _____plaintiff's insurer/subrogee ____ partial settlement ____ no settlement of the case THE _____defendant's insurer NEW YORK PEOPLE OF THE STATE OF For each question below, please circle the response that reflects your opinion, using the following TO key for your answers: 1=”Excellent!”; 2=”Good”; 3=”Adequate”; 4=”Poor”; 5=”Terrible!” 1. GREETINGS: was the procedure of court How efficient referral and arranging the mediation session? 1 2 3 4 5 WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 2. How was the mediator at explaining mediation? 1 2 3 4 5 located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed 3. or adjourned date, to testify and give evidencewas witness in this action on the part of the During the mediation session(s), how as a the mediator at: a. Giving you opportunities to express your views? 1 2 3 4 5 Your failure to comply interests and needs in this as a contempt of court and will 2 3 4 5 liable to b. Understanding your with this subpoena is punishabledispute? 1 make you the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of Treating youcomply. c. your failure to with fairness and respect? 1 2 3 4 5 Witness, Honorable 4. How was the mediator at remaining neutral? Court in County, day of , one of the Justices of the1 2 3 4 5 , 20 5. How well were the legal issues of the case identified and discussed during the session? 1 2 3 (Attorney must sign above and type name below) 4 5 6. How was the mediator at allocating appropriate time Attorney(s) for for the mediation without rushing you to reach an agreement or dragging out the process? ____Moved too quickly 1 2 3 4 5 ____ Moved too slowly ____PacedP.O. Address right Office and 7. If you reached full or partial agreement, Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: a. To what extent was the mediator responsible for it? 1 2 3 4 5 b. To what extent do you think the mediation saved you money American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. in resolving this case? 1 2 3 4 5 Plaintiff(s) : c. Please "guesstimate" how much money saved: -against- : $ JUDICIAL SUBPOENA d. To what extent do you think the mediation saved you time : in resolving this case? 1 2 3 4 5 : e. Please "guesstimate" how much time saved: Defendant(s) hours of attorney time ______ hours of your time : ...................................................... 8. If you reached full settlement, in your opinion would the case have settled later without mediation? ___ yes ___ no THE PEOPLE OF THE STATE OF NEW YORK 9. If you reached only partial agreement, to what extent was the mediator helpful in identifying possible areas of future agreement? TO 1 2 3 4 5 10. From this experience, how satisfactory do you think mediation is to resolve other disputes in which you might be involved? 1 2 3 4 5 11. Overall, how would you rate the mediation process in your case? 1 2 3 4 5 GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 12. How appropriate was the fee? ___Too High ___Too Low ___About Right located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed 13. How helpful was it that the mediator was witness in this action on the part ___Somewhat ___Not ___Very of the or adjourned date, to testify and give evidence as a a lawyer? COMMENTS: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) THANK YOU!! Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com