Mediation Request

If a hearing is scheduled for today or tomorrow, please contact the Administrative Law Judge's judicial assistant to request cancellation of the hearing so that the mediation can be scheduled:
	Salem	503-378-3308
	Portland	971-673-0900
	Eugene	541-686-7989
	Medford	541-776-6217

WCB Case Number(s):*
Claimant's Name:*
Claim Number(s):*
Hearing Date:*
Name of Submitter:*
Submitter's Phone Number:*	( )
Claimant's Attorney:*
Employer's/Insurer's Attorney:*
Other Attorneys Involved:
*Required if available

Please list at least 3 mutually-agreeable dates for all parties to conduct this mediation:
Please indicate mediator(s) preference(s) (if any):
Mediation location:
Interpreter:	No	Yes Language:

*NOTE: Written confirmation is required, with copy to opposing party/attorney.

If you have questions about the mediation program, please see our online brochure at http://www.wcb.oregon.gov/contents/medbro1.pdf, or contact the WCB Mediation Coordinator, Kerry Garrett, at 503-934-0104 (Salem) or toll free anywhere in Oregon at 1-877-311-8061, or by email at Mediation.WCB@state.or.us