Fill and Sign the Mediation Case Information Form

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