Mediator Checklist Question Title * 1. Case Name Question Title * 2. What is the mediation date? Date Date Question Title * 3. What is the mediator's name? SLB HJF JW SG TC TM ED CC MB KD JH BL JC VC AM DP KAT JM PCM JLP CJ BAF Question Title * 4. What is the case type? Civil Unruly/Delinquency Contributing Truancy Dependency/Neglect/Abuse Permanent Custody Protection Order Question Title * 5. What is the case number? (should be 8 digits, no dash). Question Title * 6. How many parents or legal custodians participated in the mediation? Question Title * 7. How long was the mediation? 0 minutes (Not held) 1-15 minutes 16-30 minutes 31-45 minutes 46-60 minutes 61-75 minutes 76-90 minutes 91-105 minutes 106-120 minutes 120 or more minutes Question Title * 8. Who was present at the mediation? Mother Father(s) Child Delinquency victim GAL/CASA Attorney Caseworker Teacher/Pupil Personnel Educational Specialist Other (please specify) Question Title * 9. How many children live in this family's household? Question Title * 10. What was the result of the mediation? Full agreement reached Partial Agreement reached Interim agreement reached No agreement reached Screened out Respondent failed to appear Petitioner failed to appear Continuance was granted Case was vacated Question Title * 11. If no mediation was held, please indicate the reason why: Not applicable. Petitioner or Complainant failed to appear Respondent or Defendant failed to appear first time Respondent or Defendant failed to appear second time Victim failed to appear first time Victim failed to appear second time Both parties failed to appear Case dismissed before mediation Case dismissed during mediation Attorney failed to appear Continuance was granted Case was vacated Question Title * 12. For grant funding purposes, what is the child's 5-digit home zip code? (Truancy, Adult Contributing, and Off-site mediations specifically) Question Title * 13. For Unruly / Delinquency Mediations, what is the name of the Complainant? (This includes Truancy) Not applicable. Other (please specify) Question Title * 14. For Unruly / Delinquency Mediations, what is the child's gender? (This includes Truancy) Not Applicable Male Female Question Title * 15. For Unruly / Delinquency Mediations, what is the child's age? (This includes Truancy) Not Applicable Age: Question Title * 16. For Unruly / Delinquency Mediations, what is the child's race or ethnicity? (This includes Truancy) Not Applicable American Indian or Alaskan Native Asian/Pacific Islander Black or African American Hispanic White/Caucasian Multiple ethnicity Other (please specify) Question Title * 17. How many people participated in this mediation? Done