Free Mediator qualification questionnaire - Ohio

APPENDIX I (L.R. 4.24, fka 4.11)

MEDIATOR QUALIFICATION QUESTIONNAIRE

Name__________________________________________________________________ Business Address_________________________________________________________ Telephone_______________________________________________________________

List any formal post-law school training for mediation (including seminars). Include the dates of the formal training:

List the number of cases you acted as mediator:

Check off the following areas you feel confident in mediating: Tort Commercial Products Liability Administrative Appeals Workers Compensation ___________________ ___________________ ___________________ ___________________ ___________________

List any professional associations affiliated with mediation:

By submitting this application, I acknowledge I am familiar with Local Rule 4.25 on mediation, and I agree to comply with those rules.

___________________________________ Signature

*This application must be submitted to: Manager, Court Administration Government Services Center 315 High Street, 3rd Floor Hamilton, Ohio 45011