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Mediation Feedback Form

To continually improve our mediation program, we would appreciate your feedback.

*-items are required.

Mediator's Name:*
Case Name:*
WCB Case Number(s):*
Date of Mediation:*
Your role in the mediation (please select):
Claimant Employer Rep.
Claimant's Attorney Insurer Rep.
Other: Emp'r/Ins'r Attorney

How would you rate your mediator in the following areas:
Not Satisfied
Very Satisfied
Knowledge of the Facts
Knowledge of Applicable Law
Conduct of the Proceeding
Judicial Temperament and Professionalism
Communication Skills
Please comment (for example: the benefits derived from the mediation, what the mediator did that was effective/not effective, suggestions for improvement of the mediation program, and/or any other thoughts you would like to share).