Singapore International Mediation Institute (SIMI)
Feedback Request Form
This Feedback Request Form will take approximately 5 to 10 minutes to complete.
When selecting from a range of options, please mark your selections with an “X“.
Please read the following introduction to the SIMI Feedback Request Form as it
contains important information to guide you in completing the form.
Thank you for your time.
Your feedback is a meaningful contribution to SIMI’s mission in promoting high standards ofprofessional competency in mediation practice. It will also:oHelp future users to have more information about working with this SIMI Mediator.

oProvide the SIMI Mediator with an opportunity to know your perception of themediation process on this occasion, how effective (s)he was, and why.

oEnable the SIMI Mediator’s Reviewer to prepare the SIMI Mediator’s Feedback Digest,
an objective and independent summary called the Feedback Digest for the SIMIMediator.

oAssist SIMI and/or the SIMI Mediator’s Reviewer to verify the mediation session for
the SIMI Mediator’s progression under the SIMI Credentialing Scheme.

You will appreciate that the SIMI Mediator’s task is a challenging one.
Fair, specific and constructive responses will be very helpful for SIMI, the SIMI Mediatorand future users.
Your feedback should focus on your experience in the mediation and with the SIMI Mediator;
not just the outcome of the mediation.

Do provide us with a way to contact you in the last section of the feedback.
Your contact information will only be used by SIMI and/or the SIMI Mediator’s Reviewer forthe clarification and/or verification purposes.
Your information, and any information about the mediation, will remain confidential and will
not be provided to third parties.

Copyright © 2015 Singapore International Mediation Institute Limited. All rights reserved.

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A.

MEDIATION INFORMATIONName Of SIMI Mediator :Start Date &Time :Mark Goh Aik Leng
Venue Of Mediation :End Date &Time :Nature Of Mediated Matter :B.

FEEDBACK ON MEDIATION PROCESS

Please put an “X” under the column that best represents your answer.

Question1.

How satisfied were you with the mediation process?

2.

How likely are you to use mediation again?

3.

How likely would you recommend mediation toothers as a dispute resolution mode?

C.

VeryHighHigh

NeutralLow

VeryLow

VeryHighHigh

NeutralLowVeryLow

FEEDBACK ON SIMI MEDIATOR

Please put an “X” under the column that best represents your answer.

Question4.

How satisfied were you with the performance ofthis SIMI Mediator?

5.

How likely are you to use this SIMI Mediator again?

6.

How likely would you recommend this SIMIMediator to others?

Copyright © 2015 Singapore International Mediation Institute Limited. All rights reserved.

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7.

How satisfied were you with the cost of your SIMIMediator?

Please be as detailed as possible in your response to the following question. You may select more than oneresponse.

Question

Response
Good control of the proceedings.
Built good rapport with the parties.
Helped explore and develop options.
Sensitive to cultural differences.

8.

What did you find that your SIMI Mediator did wellin helping the process?

Others (please describe)

Copyright © 2015 Singapore International Mediation Institute Limited. All rights reserved.

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D.

GENERAL

Please put an “X” to indicate your answer. Please be as detailed as possible in your responseto the following questions.

Question

Response9.

Was your issue resolved at the mediation?

YesNo10.

Did you use a mediation service provider?

Yes

NoIf you answered “YES” to Q10, please answer 10a and 10b.
10a.

How satisfied were you with the support provided
by the mediation service provider?

10b.

How satisfied were you with the cost of themediation service provider?

11.

Including this mediation, how many times before
have you used mediation as a form of dispute
resolution?

VeryHighHigh

NeutralLow

First time
2 to 5 times
More than 5 times
First time12.

How many times have you used this SIMI Mediator?

2 to 5 times
More than 5 times
SIMI Website
Other Website
Recommended by (Please indicate)
Lawyer, Colleague, Others

13.

How did you select this SIMI Mediator?

Appointed by mediation service
providerChosen by other party
Others (Please state below)

Copyright © 2015 Singapore International Mediation Institute Limited. All rights reserved.

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VeryLow14.

How often do you or your organisation engage
dispute resolution services?

15.

Please share any other comments, thoughts and/or
suggestions that you may have regarding themediation process or SIMI Mediator.

E.

CONTACT INFORMATIONName :

Organisation :Email Address:

Position :Contact No. :May SIMI disclose your name and contact details forthe purposes of being a reference on this SIMIMediator’s Profile on the SIMI Website?

YES / NO

Please circle accordingly

PERSONAL DATA NOTICESIMI takes the protection of your personal data very seriously. By submitting this form, you consent toour collection and use of your personal data provided on this form for the purposes of contacting you toverify information about the mediation related to this form, as well as for us to, if necessary, disclose
your personal data to our third party vendors in order for them to provide back-up, storage, security
and/or other services related to SIMI’s regular operations. Should we require the use and/or disclosureof your personal data for any other purpose, we will seek your consent before such use or disclosure.
You can find out more about SIMI’s personal data policies on our website (www.simi.org.sg). You may
also write to our Data Protection Officer at admin@simi.org.sg if you have any queries regarding yourpersonal data held by SIMI.

Thank you for contributing to thedevelopment of professional mediation in Singapore!
- END OF FORM -Copyright © 2015 Singapore International Mediation Institute Limited. All rights reserved.

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