UPDATED2019CONTRACTSATTACHMENTB_(002).pdf

ATTACHMENT B MEDIATION QUALIFICATION SHEET

NAME:

ADDRESS:

PHONE NUMBER:

FAX NUMBER:

E-MAIL ADDRESS:

I AM SEEKING A CONTRACT IN THE FOLLOWING EEOC OFFICE:

I AM AVAILABLE TO MEDIATE CASES IN THE ABOVE OFFICE IN THE FOLLOWING

SPECIFIC, GEOGRAPHIC AREAS WITHIN THIS OFFICE:

If your primary address listed above is not within the commuting area of the EEOC Office listed above, PLEASE briefly describe how you will travel to the preferred areas specifically listed in Attachment A for this office.

I AM WILLING AND QUALIFIED AND FLUENT IN THE FOLLOWING LANGUAGES

(i.e., READ, WRITE AND SPEAK REQUIRED FOR FLUENCY)

I HAVE CONDUCTED MEDIATIONS IN THE FOLLOWING FOREIGN LANGUAGES:

1. TRAINING:

A. HOW MANY HOURS OF MEDIATION TRAINING HAVE YOU RECEIVED? NAME THE

INSTITUTION OR INDIVIDUALS THAT PROVIDED THIS TRAINING AND THE DATES OF

THE TRAINING.

B. TO WHAT EXTENT WERE ALL SUBJECT MATTERS LISTED IN THE COMBINED

SYNOPSIS/SOLICITATION UNDER GENERAL REQUIREMENTS REGARDING THE

QUALIFICATIONS FOR THE MEDIATOR RELATED TO THE FIVE (5) YEARS OF

MEDIATION EXPERIENCE COVERED DURING THAT TRAINING?

C. IF YOU HAVE NOT TAKEN ANY CLASSROOM TRAINING, HOW HAVE YOU

OBTAINED THE KNOWLEDGE OF THE SUBJECT MATTER LISTED IN THE COMBINED

SYNOPSIS/SOLICITATIONUNDERGENERAL REQUIREMENTS?

2. MEDIATION EXPERIENCE:

A. HOW MANY YEARS OF MEDIATION EXPERIENCE DO YOU POSSESS? BRIEFLY

DESCRIBE THAT EXPERIENCE. HOW MANY CASES HAVE YOU MEDIATED IN THE

PAST 5 YEARS?

B. PLEASE LIST PROGRAMS, COURT SYSTEMS OR ADMINISTRATIVE BODIES WHERE

THAT EXPERIENCE WAS GAINED. HOW MANY CASES HAVE YOU MEDIATED FOR

EACH PROGRAM IN THE LAST 5 YEARS? WHAT WAS YOUR SUCCESS RATE?

WHAT OBJECTIVE DATA ARE YOU UTILIZING AND CITING IN CALCULATING

YOUR SUCCESS RATE? PLEASE PROVIDE CURRENT CONTACT INFORMATION FOR

THE ADMINISTRATOR OF EACH PROGRAM CITED (NAME, ADDRESS, PHONE, EMAIL)

3. EEO MEDIATION EXPERIENCE:

A. HOW MANY YEARS OF EEO/EEOC MEDIATION EXPERIENCE DO YOU POSSESS?

WHAT PROGRAMS, COURT SYSTEMS OR ADMINISTRATIVE BODIES WAS THIS

EXPERIENCE GAINED? HOW MANY EEO CASES HAVE YOU MEDIATED OR CO-

MEDIATED FOR THE YEARS CLAIMED? HAVE YOU SERVED AS THE LEAD MEDIATOR

IN THOSE CASES? HOW MANY EEOC MEDIATIONS HAVE YOU CONDUCTED FOR EACH

YEAR CITED, THE DATES OF SERVICE AND TYPES OF MATTERS THAT YOU

MEDIATED? WHAT WAS YOUR SUCCESS RATE? WHAT OBJECTIVE DATA ARE YOU

UTILIZING AND CITING IN CALCULATING YOUR SUCCESS RATE? PLEASE PROVIDE

CURRENT CONTACT INFORMATION FOR THE ADMINISTRATOR OF EACH PROGRAM

CITED (NAME, ADDRESS, PHONE, EMAIL)

B. IF YOU PREVIOUSLY HAVE BEEN AN EEOC CONTRACT OR PRO BONO MEDIATOR,

PLEASE LIST ALL THE OFFICES WHERE YOU WERE A CONTRACTOR OR HAVE

SERVED AS A PRO BONO MEDIATOR. PLEASE PROVIDE THE NUMBER OF EEOC

MEDIATIONS YOU HAVE CONDUCTED FOR EACH YEAR, THE DATES OF SERVICE AND

TYPES OF MATTERS YOU HAVE MEDIATED FOR THE OFFICE. WHAT WAS YOUR

SUCCESS RATE? WHAT OBJECTIVE DATA ARE YOU UTILIZING AND CITING IN

CALCULATING YOUR SUCCESS RATE? PLEASE PROVIDE CURRENT CONTACT

INFORMATION FOR THE EEOC ADR COORDINATOR CONTRACT ADMINISTRATOR FOR

EACH EEOC PROGRAM CITED (NAME, ADDRESS, PHONE, EMAIL)

C. IF YOU WERE AN EEOC CONTRACT OR PRO BONO MEDIATOR, WERE YOU EVER

REMOVED FROM THE EEOC MEDIATOR PANEL OR DENIED AN OPTION TO CONTINUE

AS A MEDIATOR? WERE YOU EVER COUNSELED BY AN EEOC OFFICIAL ABOUT

MEDIATION PRACTICES INCONSISTENT WITH THE EEOC’S MEDIATION PROGRAM? IF

SO, LIST THE OFFICE AND THE EEOC ADR COORDINATOR THAT COUNSELED YOU OR

INFORMED YOU OF THIS ACTION.

D. WERE YOU EVER AN EEOC STAFF MEDIATOR? IF SO, PLEASE LIST ALL THE

OFFICES WHERE YOU SERVED? PLEASE PROVIDE THE NUMBER OF EEOC

MEDIATIONS THAT YOU HAVE CONDUCTED FOR THE LAST FIVE YEARS OF YOUR

EEOC SERVICE, THE DATES OF SERVICE AND THE OFFICE. WHAT WAS YOUR

SUCCESS RATE? WHAT OBJECTIVE DATA ARE YOU UTILIZING AND CITING IN

CALCULATING YOUR SUCCESS RATE? PLEASE PROVIDE CURRENT CONTACT

INFORMATION FOR THE EEOC OFFICIAL(S) THAT SUPERVISED YOU THE LAST FIVE

YEARS OF YOUR EEOC SERVICE FOR EACH EEOC OFFICE CITED (NAME, ADDRESS,

PHONE, EMAIL)

E. HOW HAVE YOU OBTAINED THE KNOWLEDGE OF THE SUBJECT MATTER LISTED IN

THE COMBINED SYNOPSIS/SOLICITATION UNDER GENERAL REQUIREMENTS

REGARDING THE QUALIFICATIONS FOR THE MEDIATOR RELATED TO EEO

EXPERIENCE?

List below two references who may be contacted that are familiar with your relevant past mediation case experience

Name

List below the name of any contracting office, date of contract and the name and telephone number, e-mail address, fax number of the contract administrator of the contract for any contract where you provided mediation service during the past three years.

Contact Information Name Mediation program Phone E-mail Fax

Contact Information Name Mediation program Phone E-mail Fax

I attest that the information that I have provided concerning my mediation training and mediation experience is accurate and truthful. I recognize and understand that failure to provide truthful and accurate information is grounds for consideration and removal as a mediator under this solicitation.

Signed:

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