FOR OFFICE USE ONLY State of New Jersey DATE RECEIVED: MEDIATION CASE INFORMATION FORM DATE ENTERED - AOC: Statewide Civil, General Equity and Probate Mediation Program DIRECTIONS: This form is to be completed by the mediator when the mediation is concluded or returned to court. CASE DOCKET NUMBER COUNTY LAST NAME OF MEDIATOR FIRST NAME OF MEDIATOR OUTCOME / NATURE OF AGREEMENT mediation held / full agreement on all issues mediation held / no agreement no mediation held / party failed to attend mediation held / some issues pending no mediation held / parties settled case before mediation session no mediation held / party attended but failed to participate SOURCE OF REFERRAL MANNER OF MEDIATOR SELECTION motion / request of plaintiff bench referral DATE CASE ASSIGNED TO MEDIATOR motion / request of defendant consent request by both parties DATE OF INITIAL MEDIATION SESSION NUMBER OF MEDIATION SESSIONS DID THE ATTORNEYS SUBMIT PROPER CASE SUMMARIES? NUMBER OF HOURS IN SESSIONS WERE THE ATTORNEYS PREPARED FOR THE MEDIATION SESSIONS? no AT WHAT STAGE IN THE CASE DID THE MEDIATION SESSION TAKE PLACE? (note all that are applicable) selected by parties DATE OF FINAL MEDIATION SESSION NUMBER OF HOURS OF PREPARATION TIME yes assigned by court yes no NUMBER OF HOURS PAID BY PARTIES WERE THE PARTIES PREPARED FOR THE MEDIATION SESSIONS? yes no before depositions after experts' reports served after interrogatories and document production WAS THE TIMING OF REFERRAL TO MEDIATION APPROPRIATE? before any discovery after depositions after first trial date scheduled too early HAD THIS CASE UNDERGONE ANY PRIOR CDR TECHNIQUE? (e.g. arbitration, early neutral evaluation) appropriate time too late TYPE OF CDR yes IF THE CASE DID NOT SETTLE IN MEDIATION, WHAT WERE THE REASONS? (note all that are applicable) APPROXIMATE DATE no issues were too complex one or both parties did not mediate in good faith RELATIONSHIP OF PARTIES the proper parties with authority to settle were not present issues were too numerous formal business relationship (eg. partnership, corporation) performance of service contract employee family one or both parties too entrenched in their positions friend neighbor no ongoing relationship COMMENTS (Please use this section to note any suggestions, concerns or other comments on the pilot program.) PLEASE RETURN TO: Revised 6/21/2005, CN10526-english AOC - CIVIL PRACTICE DIVISION BOX 981 TRENTON, NJ 08625 FAX: 609 777-0844 page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com