**[MEDIATION CUSTOMER FEEDBACK FORM]{.underline}**

To evaluate and improve the Department of Veterans Affairs (VA)
Mediation Program, persons who have participated in the Program are
requested to complete this survey. Please return the survey to Tia
Little, VA Central Office Mediation Coordinator, at 1575 I Street,
10^th^ Floor, NW, Washington, DC 20005, 202-501-2885 (fax) or
<tia.little@va.gov> .

ADR Case Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Your Role in the Mediation:

\_\_\_\_\_\_\_\_Employee

\_\_\_\_\_\_\_\_Management Official

\_\_\_\_\_\_\_\_Representative

**PRIOR TO THE MEDIATION SESSION:**

Did you have enough information to prepare? \_\_\_\_\_\_\_\_ Yes
\_\_\_\_\_\_\_ No

If yes, please identify anything that was particularly helpful.
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If no, please identify any information that would have been useful.
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**MEDIATION PROCESS:**

1 = strongly disagree; 2 = somewhat disagree; 3 = neither agree nor
disagree; 4 = somewhat agree; 5 = strongly agree

The mediation location was acceptable. 1 2 3 4 5

The right parties were at the table. 1 2 3 4 5

Mediation was appropriate for this dispute. 1 2 3 4 5

**MEDIATOR(S):**

The mediator(s) explained the process well. 1 2 3 4 5

The mediator(s) were impartial. 1 2 3 4 5

The mediator(s) assisted the parties in communicating

and exploring options for resolution. 1 2 3 4 5

If there was a co-mediator, was it beneficial having two mediators?

\_\_\_\_\_\_\_Yes \_\_\_\_\_\_No

If you elected to have a VA mediator, please explain why?
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If you elected to have a non-VA mediator, please explain why?

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**OUTCOME:**

I understand the other party's perspective better

as a result of the process. 1 2 3 4 5

I think my relationship with the other party will

improve as a result of participating in mediation. 1 2 3 4 5

If an agreement was reached, were you satisfied with the terms?

\_\_\_\_\_\_\_ Yes \_\_\_\_\_\_No

If an agreement was not reached, did you benefit from the mediation
process?

\_\_\_\_\_\_\_\_Yes \_\_\_\_\_\_No

If so, please describe anything gained from the experience.

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Would you use mediation again? \_\_\_\_\_\_\_\_\_Yes \_\_\_\_\_\_\_No

What did you learn from the mediation process-advantages/disadvantages
of mediating?

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Would you recommend mediation to another VA employee or manager?

\_\_\_\_\_\_\_\_\_\_Yes \_\_\_\_\_\_\_No

What can be done to improve the program-how could the process have been
more helpful in resolving the issues?
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**Thank you for your time and feedback.**