OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA VERIFICATION OF OBSERVATION FORM Please use black ink so this document will be legible when scanned. (To be completed by Mentor and returned to Mentee within ten days following case completion.) Please type or print. SECTION I. 1. 2. BACKGROUND INFORMATION Name of Mentee: _____________________________________________________ Name of Mentor: _____________________________________________________ (Are you currently certified as a Mentor for this court level? ____Yes ____No) 3. Certification Number: ________________________________________________ OBSERVATION INFORMATION SECTION II. 1. 2. 3. Date(s) of Observation: ________________________________________________ Nature of Case: GDC _____ J&DR _____ CCC _____ CCF _____ Other______ Length of Mediation: _________________________________________________ 4. Describe the Mentee's participation in the de-briefing session. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 5. Additional comments: _________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ________________________________________________ Signature of Mentor Mediator ______________________ Date FORM ADR-1007 (1/09) American LegalNet, Inc. www.FormsWorkflow.com