Conflict Resolution Questionnaire

Conflict Resolution Questionnaire and Engagement Agreement

WHEREAS

WHEREAS, Client Name: asserts that a dispute has arisen between Client and Respondent Name: concerning the matters described herein;

WHEREAS, the parties wish to document the facts, prior efforts to resolve the dispute, proposed outcomes, and the terms under which a neutral may be retained to assist in resolving the dispute; and

WHEREAS, the parties acknowledge that completion of this questionnaire is a condition precedent to engagement of any mediator, arbitrator, or neutral listed by an organization or selected by the parties.

SCOPE OF ENGAGEMENT

The neutral, upon agreement of the parties, will perform services limited to the scope described above. Services may include document review, facilitation of settlement discussions, private caucus sessions, recommended settlement frameworks, or conducting a binding or non-binding hearing as agreed by the parties.

INCIDENT OVERVIEW

Date(s) of incident: . Approximate period of dispute:

PARTIES AND CONTACTS

PRIOR RESOLUTION EFFORTS

Check all prior efforts attempted:
Direct negotiation between parties    Internal grievance or complaint process    Formal complaint to regulator or employer
Prior mediation    Prior arbitration    Litigation filed

DESIRED OUTCOME AND REMEDIES

EVIDENCE, DOCUMENTS AND WITNESSES

LEGAL REPRESENTATION

Is the party represented by counsel?   Claimant represented    Respondent represented

PREFERRED METHODS AND TIMELINE

Preferred method of resolution:
Negotiation    Mediation    Arbitration    Litigation

CONFIDENTIALITY

All communications made for the purpose of settlement or during mediation sessions shall be treated as confidential settlement communications to the fullest extent permitted by law. Such confidentiality includes prohibitions on disclosure in subsequent litigation or proceedings, except where disclosure is mandated by statute, court order, or where a party demonstrates good cause that confidentiality should not apply.

Parties acknowledge and agree that the neutral shall not be called as a witness in any subsequent proceeding regarding the substance of the mediation unless both parties provide written consent.

Acknowledgement of confidentiality requirement: I acknowledge and agree

PAYMENT TERMS

The party or parties engaging the neutral agree to the following fees and payment schedule.

Unpaid fees not timely remitted may accrue interest or suspensions of services as set forth above. Parties remain jointly and severally liable for agreed sums unless otherwise specified.

TERM AND TERMINATION

Engagement start date:    Engagement end date or review date:

Either party may terminate this engagement for material breach or upon written notice as provided above. Termination does not relieve the terminating party of amounts owing for services rendered and costs incurred prior to termination.

GOVERNING LAW

This Agreement and any dispute arising out of or relating to this Agreement shall be governed by and construed in accordance with the laws of the State of: without regard to its conflict of laws principles.

ENTIRE AGREEMENT

This document, including the responses provided in this questionnaire, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements, understandings, negotiations and discussions, whether oral or written. Any amendment must be in writing and signed by both parties.

CERTIFICATION

By signing below, each signatory certifies that the information provided in this questionnaire is true and complete to the best of their knowledge, that they are authorized to execute this Agreement on behalf of the party identified, and that they consent to the engagement terms and confidentiality provisions set forth above.

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