1 ADR Docketing Statement (WACO DIVISION ONLY) A. Case Number : B. Case Name: C. Attorney (or Party, if pro se) filing evaluation form: 1. Name Firm Address Client Telephone FAX D. Nature of Relief Sought (Check all that apply): 1. Injunctive Relief 2. Damages: Amount 3. Declaratory Relief (Describe): 4. Attorney Fees Amount 5. Other E. Brief Description of Nature of Action: F. Status of Settlement Negotiations to Date: 1. Have settlement negotiations been held? Yes No 2. If yes: Only Counsel Participated Parties as Well as Counsel Participated 3. What is the present status of negotiations? 1 ADR refers to Alternative Dispute Resolution >>>> 2 4. If settlement negotiations have not been held, why not? G. Evaluation: 1. Could this dispute benefit from the use of some form of ADR? Yes No a. Reason for choice (must be completed): 2 b. If yes, what form of ADR would best suit this case Mediation Early Neutral Evaluation Advisory Arbitration Moderated Settlement Conference Mini-Trial Judicial Settlement Conference Summary Jury Trial 2. Describe any discovery you believe necessary to utilize ADR effectively: 3. Have you discussed ADR with other counsel and their clients? Yes No 4. Will all parties agree to submit the case to ADR? Yes No Unsure a. If yes, have the parties agreed to: 1. An ADR process? 2. A provider? 3. A tentative date for the ADR proceeding? Failure to fully complete this form may result in sanctions pursuant to Fed.R.Civ.P.(16)f. 2 For further information on dispute resolution procedures, contact the Clerk.