Attachment B
Department of Veterans Affairs
VISN X Mediation Program
Mediation Request/Consent Form
1. The parties and their representatives understand that mediation is a voluntary and confidential process, and that no party shall be bound by anything said or done at the mediation, unless a written settlement agreement is reached and executed by all necessary parties. If a settlement is reached, the agreement shall be reduced to writing by the Mediator(s) and, when signed and approved by the appropriate authorities for all of the parties, the settlement shall be legally binding upon all parties to the agreement.
2. In electing to use mediation, the parties and their representatives understand that they are not waiving statutory deadlines.
3. In the event mediation is terminated for any reason, the aggrieved person may continue to pursue an informal or formal resolution of the matter.
4. The issue(s) for mediation (please describe):
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5. Each party involved in this matter is requested to sign the request document and indicate whether they are willing to participate in mediation:
Initiating Party: _______________________________________________________
[name, telephone number] ___________________________ Date ________
o I understand the above information, agree that mediation is a proper way to attempt to resolve the issue(s),
and agree to participate in the mediation process.
o I understand the above information, but have decided not to participate at this time.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Union Representative (if appropriate): _________________________________________________
[name, telephone number] __________________________ Date ________
o I understand the above information, agree that mediation is a proper way to attempt to resolve the issue(s),
and agree to participate in the mediation process.
o I understand the above information, but have decided not to participate at this time.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Other Party: ______________________________________________________
[name, telephone number] ___________________________ Date ________
o I understand the above information, agree that mediation is a proper way to attempt to resolve the issue(s),
and agree to participate in the mediation process.
o I (we) understand the above information, but have decided not to participate at this time.
Other Party Representative (if appropriate): __________________________________________________
[name, telephone number] ___________________________ Date ________
o I understand the above information, agree that mediation is a proper way to attempt to resolve the issue(s),
and agree to participate in the mediation process.
o I understand the above information, but have decided not to participate at this time.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Other Party (if appropriate): ___________________________________________________
[name, telephone number] ___________________________ Date _________
o I understand the above information, agree that mediation is a proper way to attempt to resolve the issue(s),
and agree to participate in the mediation process.
o I understand the above information, but have decided not to participate at this time.
