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Mediators Survey 34 - Pennsylvania
| Mediators Survey Form. This is a Pennsylvania form and can be used in USBC Western Federal . |
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WPAB FORM 34 (03/12) Page 1 IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA MEDIATOR'S SURVEY We need your help to evaluate the effectiveness of the Mediation Program. Please complete this form and return it to: The Honorable Judith K. Fitzgerald, Mediation Program Administrator, to the attention of John Horner, Clerk of Court 5414 U.S. Steel Tower 600 Grant Street Pittsburgh, PA 15219 This information will be used solely for the purpose of evaluating the Mediation Program. 1. Case Name: Case No. Chapter: Adv. Name: Adv. No. ____________________________________________________________ ____________________________________________________________ ______7 _______11 _______12 _______13 ____________________________________________________________ ____________________________________________________________ 2. 3. No. Related to Document No. _______________________________________________ 4. 5. 6. When were you appointed as mediator? _______________________________________ When did the mediation take place? __________________________________________ Where did you meet? ______ Mediator's Office ______ Courthouse ______ Office of a Party ______ Office of a Party's Attorney ______ Other (specify) ____________________________________________________ How long was the mediation? ______ less than 1 hour ______ 1-2 hours ______ 3-4 hours ______ one day ______ more than one day (specify number of days) _____________________________ The dispute that you mediated was: ______ totally resolved (subject to Court approval) ______ partially resolved (certain issues were settled) ______ partially resolved (certain issues were narrowed for litigation) ______ not resolved American LegalNet, Inc. www.FormsWorkFlow.com 7. 8. WPAB FORM 34 (03/12) Page 2 9. In your opinion, did each party have a representative with full settlement authority at the mediation conference? _____yes _____no 10. Did the parties who attended the mediation conference participate in good faith? ____ yes ____ no 11. What was the type of proceeding? ______ non-dischargeability (specify basis) ยง523(a)(_____) ______ objection to claim ______ preference ______ fraudulent transfer ______ turnover ______ administrative expense ______ valuation ______ other (specify) _____________________________________________________ How much money was claimed in the dispute? ______ under $1,000 ______ $1,000 to $5,000 ______ $5,000 to $10,000 ______ $10,000 to $50,000 ______ $50,000 to $100,000 ______ $100,000 to $500,000 ______ over $500,000 ______ nonmonetary issue (specify) __________________________________________ The plaintiff or movant was a[n]: ______ trustee ______ individual ______ corporation ______ partnership ______ Internal Revenue Service ______ other (specify) _____________________________________________________ The defendant or respondent was a[n] ______ trustee ______ individual ______ corporation ______ partnership ______ Internal Revenue Service ______ other (specify) _____________________________________________________ 12. 13. 14. 15. What did you dislike about the mediation conference? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com WPAB FORM 34 (03/12) Page 3 16. What did you like about the mediation conference? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 17. How can the Mediation Program be improved? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 18. Please include below any additional comments regarding the mediation conference in which you participated or regarding the Court's Mediation Program ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Dated:__________________ ________________________________________________ Mediator ________________________________________________ Please type or print name American LegalNet, Inc. www.FormsWorkFlow.com
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