RFQ0113-14_ATTACHMENT_B.pdf

ATTACHMENT B

MEDIATION QUALIFICATION SHEET

NAME:

I AM WILLING AND FLUENT IN THE FOLLOWING LANGUAGES (i.e., READ, WRITE AND SPEAK

REQUIRED FOR FLUENCY). PLEASE INDICATE IF SUCH SKILL INCLUDES SIGN LANGUAGE.

PLEASE LIST WHERE YOU ARE AVAILABLE TO MEDIATE CHARGES OF DISCRIMINATION

WITHIN THIS OFFICE'S GEOGRAPHICAL JURISDICTION (LIST CITIES, MUNICIPALITIES,

COUNTIES, STATES).

E-MAIL ADDRESS:

PHONE NUMBER:

ADDRESS:

I HAVE CONDUCTED MEDIATIONS IN THE FOLLOWING FOREIGN LANGUAGES (including sign language). PLEASE INDICATE THE NUMBER OF SUCH MEDIATIONS CONDUCTED IN THE PAST 12 MONTHS AND LAST THREE YEARS AND THE TYPE OF DISPUTE (e.g., EEO, COMMUNITY, FAMILY LAW)

FAX NUMBER:

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

GENERAL MEDIATION EXPERIENCE COVERED DURING THAT TRAINING?

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.

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

OBTAINED THE KNOWLEDGE OF THE SUBJECT MATTER LISTED IN THE COMBINED

SYNOPSIS/SOLICITATION UNDER GENERAL 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 YOU LISTED (NAME, ADDRESS, PHONE, EMAIL)

3. EEO MEDIATION EXPERIENCE:

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

DID YOU GAIN YOUR EXPERIENCE MEDIATING EEO CASES - LIST PROGRAMS, COURT

SYSTEMS OR ADMINISTRATIVE BODIES. HOW MANY EEO CASES HAVE YOU

MEDIATED OR CO-MEDIATED FOR THE YEARS CLAIMED? HAVE YOU SERVED AS THE

LEAD MEDIATOR IN THOSE CASES? WHAT WERE 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 EEOC PRO BONO MEDIATOR,

PLEASE LIST ALL THE EEOC 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 AND 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 CONTRACTOR OR EEOC PRO BONO MEDIATOR, WERE YOU EVER

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

MEDIATOR? IF SO, LIST THE OFFICE AND THE EEOC ADR COORDINATOR THAT 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 THREE 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 THREE 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 Contact Information Name Contact Information

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.

Contracting Office Date of Contract Name of Administrator Phone E-mail Fax

I attest that the information that I have provided concerning my mediation training and experience is accurate and truthful. I recognize and understand that failure to provide truthful and accurate information, is grounds for removal as a mediator in your program.

Signed:

Print Name:

Date:

Contracting Office Date of Contract Name of Administrator Phone E-mail Fax

Contracting Office Date of Contract Name of Administrator Phone E-mail Fax

ATTACHMENT B

MEDIATION QUALIFICATION SHEET

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

I attest that the information that I have provided concerning my mediation training and experience is accurate and truthful. I recognize and understand that failure to provide truthful and accurate information, is grounds for removal as a mediator in your program.

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