Medical College of Georgia Administrative Policies and Procedures
Office of Primary Responsibility: Vice President for Legal Affairs
No. 1.4.30

Exhibit "A"

MEDIATION INTAKE FORM

1.  Person requesting mediation:

Phone #:

Date of initial contact:

Nature of the conflict:

Is mediation appropriate? Yes:      No:
If no, why not:

If mediation is appropriate, is this person willing to participate? Yes:

2.  Other potential party to mediation:

Phone #:

Is this person willing to participate in mediation? Yes:      No:
If no, why not:

Original party informed that mediation will not occur: Yes: Date:

3.  If both parties agree to mediation, who will mediate:

Are there any anticipated expenses? Yes:      No:
If yes, provide details: 

4.  Follow up survey sent on: