Attachment D
VISN MEDIATION PROGRAM SAMPLE
DRAFT ATTACHMENT D
Department of Veterans Affairs VISN X Mediation Program USER SATISFACTION SURVEY To find ways to assess and improve the VISN X Mediation Program, persons who have participated in the Program are requested to complete this questionnaire. Your assistance is voluntary, but will help us with making the necessary improvements! Please return the questionnaire to the appropriate local management official designated to coordinating mediation requests, or mail to: VISN X Mediation Program Survey Results, Office of Regional Counsel Region 23 (318/02), 251 N. Main Street, Winston-Salem, NC 27155. 1. VA facility: _____________________________________________________ 2. Name of matter: _________________________________________________ 3. Type(s) of issues: ________________________________________________ 4. Describe the type of settlement that resulted form the mediation process.
5. Please describe any other impacts or benefits that you felt resulted from the mediation process. Examples might include relationships repaired, communication enhanced, office productivity enhanced, money saved, etc. _____________________________________________________________________ 6. Were you satisfied with the process?
Please provide any comments _________________________________________ 7. Would you use mediation again?
Please provide any comments _________________________________________ 8. Is there anything that you think should be done to improve the VISN X mediation Program?
Please provide any comments ______________________________________________________________ ______________________________________________________________________________________ 9. Please rate the following items on a scale of 1 to 5 by circling the number that represents your choice: 1 = strongly disagree 2 = somewhat disagree 3 = neither agree or disagree 4 = somewhat agree 5 = strongly agree N = don’t know or are unable to determine a. The mediation process was impartial. 1 2 3 4 5 N b. The right parties were at the table. 1 2 3 4 5 N c. Both sides negotiated in good faith. 1 2 3 4 5 N d. Mediation was appropriate for this matter. 1 2 3 4 5 N e. You were able to fully present your case. 1 2 3 4 5 N f. The mediator helped create a positive g. The mediator helped create realistic h. The mediator was impartial. 1 2 3 4 5 N i. The mediator participated the right amount. 1 2 3 4 5 N j. The mediator listened well. 1 2 3 4 5 N i. The mediator helped clarify the k. The mediator explained the process well. 1 2 3 4 5 N l. The mediator was fair. 1 2 3 4 5 N m. The mediator was effective. 1 2 3 4 5 N
10. If this was a co-mediation, was it beneficial to have two mediators?
Please provide any comments ______________________________________________________________ ______________________________________________________________________________________ 11. Please provide any other comments: ______________________________________________________ ______________________________________________________________________________________ Thank you for taking the time to complete this questionnaire. Please return it to the appropriate local management official designated to coordinating mediation requests, or mail to: VISN X Mediation Program Survey Results, Office of Regional Counsel (). |