**[MEDIATOR\'S SURVEY]{.underline}**

ADR is a new program in this District. We need your help to evaluate the
effectiveness of the ADR program. Please complete this form and return
it to: ADR Program Administrator, United States Bankruptcy Court, 230
North First Avenue, Suite 101 Phoenix, Arizona 85003-1706 or E-Mail
completed electronic version ~~in pdf format to~~:
*ADRprogramadmin@azb.uscourts.gov* within \_\_\_\_\_ days. This
information will be used solely for the purpose of evaluating the ADR
program.

1.  Case Name:

> Case No.

2.  Chapter: \_\_\_\_\_ 7 \_\_\_\_\_ 11 \_\_\_\_\_ 12 \_\_\_\_\_ 13

3.  Adv. Name:

> Adv. No.:

4.  When were you appointed as mediator?

5.  When did the mediation take place?

6.  Where did you meet?

> \_\_\_\_\_ Mediator\'s Office
>
> \_\_\_\_\_ Courthouse
>
> \_\_\_\_\_ Office of a Party
>
> \_\_\_\_\_ Office of a Party\'s Attorney
>
> \_\_\_\_\_ Other (specify)

7.  How long was the mediation?

> \_\_\_\_\_ less than 1 hour
>
> \_\_\_\_\_ 1-2 hours
>
> \_\_\_\_\_ 3-4 hours
>
> \_\_\_\_\_ one day
>
> \_\_\_\_\_ more than one day (specify number of days)

8.  The dispute that you mediated was:

> \_\_\_\_\_ totally resolved (subject to court approval)
>
> \_\_\_\_\_ partially resolved (certain issues were settled)
>
> \_\_\_\_\_ partially resolved (certain issues were narrowed for
> litigation)
>
> \_\_\_\_\_ not resolved

9.  In your opinion, did each party that participated in the ADR
    conference (either directly or through a representative) have full
    settlement authority? \_\_\_\_\_ yes \_\_\_\_\_ no

10. Did the parties who attended the ADR conference participate in good
    faith? \_\_\_\_\_ yes \_\_\_\_\_ no

11. What was the type or nature of proceeding?

> \_\_\_\_\_ non-dischargeability (specify basis) 11 U.S.C.
> § 523(a)(\_\_\_\_)
>
> \_\_\_\_\_ objection to claim
>
> \_\_\_\_\_ preference
>
> \_\_\_\_\_ fraudulent transfer
>
> \_\_\_\_\_ turnover
>
> \_\_\_\_\_ administrative expense
>
> \_\_\_\_\_ valuation
>
> \_\_\_\_\_ other (specify)

12. How much money was involved in the dispute?

> \_\_\_\_\_ under \$1,000
>
> \_\_\_\_\_ \$1,000 to \$5,000
>
> \_\_\_\_\_ \$5,000 to \$10,000
>
> \_\_\_\_\_ \$10,000 to \$50,000
>
> \_\_\_\_\_ \$50,000 to \$100,000
>
> \_\_\_\_\_ \$100,000 to \$500,000
>
> \_\_\_\_\_ over \$500,000
>
> \_\_\_\_\_ nonmonetary issue (specify)

13. The plaintiff or Movant was a\[n\]:

> \_\_\_\_\_ trustee
>
> \_\_\_\_\_ individual
>
> \_\_\_\_\_ corporation
>
> \_\_\_\_\_ partnership
>
> \_\_\_\_\_ Internal Revenue Service
>
> \_\_\_\_\_ other (specify)

14. The defendant(s) or Respondent(s) was a\[n\]:

> \_\_\_\_\_ trustee
>
> \_\_\_\_\_ individual
>
> \_\_\_\_\_ corporation
>
> \_\_\_\_\_ partnership
>
> \_\_\_\_\_ Internal Revenue Service
>
> \_\_\_\_\_ other (specify)

15. What did you dislike about the ADR conference?

16. What did you like about the ADR conference?

17. How can the ADR program be improved?

18. What additional training and/or education do you believe would be
    useful for you in conducting future ADR conferences?

19. Please include below any additional comments regarding the ADR
    conference in which you participated or regarding the Court\'s ADR
    program.

Dated:

> Mediator
>
> Please type or print name
>
> **DO NOT FILE IN THE CASE, SUBMIT BY E-MAIL TO:**
>
> **ADRprogramadmin@azb.uscourts.gov**