OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA TRAINEE EVALUATION FORM Please use black ink so this document will be legible when scanned. (Trainers, please do not complete this Form unless the Trainee has attended the entire course.) 1. Name of Trainee 2. Name of Trainer 3. Name of Training Course 4. Date of Training 5. Length of Training Basic or Family Mediation Training Please check which training: Basic 6. How many times did the trainee serve as a mediator? Based on your observation, do you believe that the trainee: 7. Has grasped the basic concepts of mediation? Yes No Family Certification Number 8. Demonstrates an understanding of the role of the mediator and the stages of mediation? Yes No 9. Demonstrates an understanding of the skills necessary for good mediation practice? Yes No 10. Demonstrates an understanding of the ethical standards that apply to certified mediators? Yes No 11. Is the trainee ready to continue with the mentorship process? Yes No 12. If you answered "No" to any of the questions above, please explain the following: a. Why you answered "No" b. What additional training you would recommend c. What other suggestions you have Orientation to Virginia's Judicial System Training 13. Based on your observation, do you believe the trainee demonstrates an understanding of how mediation can be an alternative to litigation in the judicial process and the basic structure of Virginia's judicial system? Yes No If you answered "No", please explain why FORM ADR-1006 July 2011 1 American LegalNet, Inc. www.FormsWorkFlow.com Screening For and Dealing With Domestic Abuse in the Mediation Context Training 14. Based on your observation, do you believe the trainee demonstrates an understanding of: a. b. c. d. e. the scope of the domestic abuse problem? how to screen cases for domestic abuse? how to decide whether to mediate if abuse is disclosed? safety precautions to use during mediation? how to terminate mediation when it is inappropriate? Yes Yes Yes Yes Yes No No No No No If you answered "No", please explain why 15. How many times did the trainee serve as a mediator? Certified Observation Training 16. Based on your observation, do you believe the trainee received sufficient opportunities to observe mediations and serve in the role of mediator to enable them to be prepared to proceed with comediations? Yes No If you answered "No", please explain why Circuit Court-Civil or Circuit Court-Family Training Please check training: CCC CCF 17. Based on your observation, do you believe the trainee demonstrates an understanding of the advanced substantive and skills information presented? Yes No If you answered "No", please explain why Advanced Certificate Mediation Training 18. Based on your observation, do you believe the trainee demonstrates an understanding of the advanced substantive and skills information presented? Yes No If you answered "No", please explain why Mentoring Others Training 19. Based on your observation, do you believe the trainee demonstrates an understanding of mentor responsibilities? Yes No If "No", please explain why Trainers Of All Certified Courses Please Answer: 20. Did the trainee successfully complete this course? Yes SIGNATURE OF TRAINER No DATE FORM ADR-1006 July 2011 2 American LegalNet, Inc. www.FormsWorkFlow.com