Indiana Conflict Resolution Institute Alternative Dispute Resolution Provider Survey

Indiana Conflict Resolution Institute
Alternative Dispute Resolution Provider Survey

This form will record your individual information, and will send it electronically to the ICRI staff. Please fill out any relevant fields, and add specific information when requested. You may leave fields blank. Make sure to check "yes" if you would like your information posted on the Indiana Conflict Resolution Institute ADR providers database. When you finish the survey, please click "submit". Click here to search our database for other ADR providers. For more information on the ADR Provider Survey, please see the description.

Please be sure to include an e-mail address or phone and fax number when completing the ADR Provider survey. ICRI staff will review survey information and you will be contacted to verify the information. No survey information will be added to the web searchable database until the individual provider has verified the information.

Last Name:

First Name, MI:

Title:

Occupation:

Company:

Address:



Phone:

Fax:

Email:

Web:


Undergraduate School, Degree and Year:

Graduate School, Degree and Year:

Professional School, Degree and Year:

Association Memberships:
Indiana Bar Association
American Bar Association
Indiana Association of Mediators
Indiana Chapter, Society for Professionals in Dispute Resolution
Other, Please List

Professional Panel Approval:
American Arbitration Association
CPR Institute
NASD (National Association of Securities Dealers)
IEERB (Indiana Educational Employment Relations Board)
FMCS (Federal Mediation and Conciliation Service)
Other, Please List

Professional Licenses:
Indiana Bar
Registry of Court Mediators
Other, Please List

Publications:

What ADR services do you provide?
Mediation                                        Partnering
Arbitration                                       Early Neutral Evaluation
Facilitation
Summary Jury Trials
Other, please specify

Experience:
Construction                                    Labor
Environmental                                  Real Estate
Domestic Relations                         Torts
Employment
Other, please specify

Number of cases mediated in last three years:
1996

1997

1998

Number of cases arbitrated in last three years:
1996

1997

1998

How many hours have you spent on ADR case-related work in the last 12 months:
0-200 hours
201-500 hours
501-1000 hours
1001-2000 hours
More than 2000 hours

Total number of years you have served as a neutral:
Less than 1
1-2
3-5
6-10
More than 10

What ADR training have you received? (Please specify dates)

Do you have any special qualifications (i.e. former judge, multi-lingual, American Sign Language, etc.)?

Please describe the ADR approach or philosophy that governs your style:

How do you bill your clients (i.e. hourly; daily; per case; whether there is/is not resolution; fee plus expenses, etc.)?

Are you willing to travel out of your area for a case?
Yes
No

If you are willing to travel out of your area, how much do you charge for your travel?

On average, how soon after a request are you able to hear or mediate a case?
1 week
2 weeks
1 month
2 months
Unpredictable

May we use this information on the ICRI website roster of dispute resolution providers?
Yes
No

Indiana Conflict Resolution Institute
Last updated: July 30, 2004
Comments: ICRI Administrator
Copyright 1999 - Indiana University, Bloomington